The Hot Zone
By Richard Preston
EBOLA RIVER
1976 SUMMER - AUTUMN
ONE JULY 6, 1976, five hundred miles northwest of Mount Elgon, in
southern Sudan, near the fingered edge of the central-African rain forest, a
man who is known to Ebola hunters as Yu. G. went into shock and died with
blood running from the orifices of his body. He is referred to only by his
initials. Mr. Yu. G. was the first identified case, the index case, in an
outbreak of an unknown virus.
Mr. Yu. G. was a storekeeper in a cotton factory in the town of Nzara. The
population of Nzara had grown in recent years – the town had experienced,
in its own way, the human population explosion that is occurring through the
equatorial regions of the earth. The people of that area in southern Sudan are
the Zande, a large tribe. The country of the Zande is savanna mixed with
riverine forest, beautiful country, where acacia trees cluster along the banks
of seasonal rivers. African doves perch in the trees and call their drawn-out
calls. The land between the rivers is a sea of elephant grass, which can grow ten feet height. As you head south, toward Zaire, the land rises and forms
hills, and the forest begins to spread away from the rivers and thickens into a
closed canopy, and you enter the rain forest. The land around the town of
Nzara held rich plantations of teak and fruit trees and cotton. People were
poor, but they worked hard and raised large families and kept to their tribal
traditions.
Mr. Yu. G. was a salaried man. He worked at a desk in a room piled with
cotton cloth at the back of the factory. Bats roosted in the ceiling of the room
near his desk. If the bats were infected with Ebola, no one has been able to
prove it. The virus may have entered the cotton factory by some unknown
route – perhaps in insects trapped in the cotton fibers, for example, or in rats
that lived in the factory. Or, possibly, the virus had nothing to do with the
cotton factory, and Mr. Yu. G. was infected somewhere else. He did not go
to a hospital, and died on a cot in his family compound. His family gave him
a traditional Zande funeral and left his body under a mound of stones in a
clearing of elephant grass.
His grave has been visited more than once by doctors from Europe and
America, who want to see it and reflect on its meaning, and pay their
respects to the index case of what later became known as Ebola Sudan.
He is remembered today as a "quiet, unremarkable man." No photograph
was taken of him during his lifetime, and no one seems to remember what he
looked like. He wasn't well known, even in his hometown.
They say that his brother was tall and slender, so perhaps, he was, too.
He passed through the gates of life unnoticed by anyone except his family
and a few of his co-workers. He might have made no difference except for
the fact what he was a host.
His illness began to copy itself. A few days after he died, two other salaried
men who worked at desks near him in the same room broke with bleeding,
went into shock, and died with massive hemorrhages from the natural
openings of the body. One of the dead men was a popular fellow known as
P.G. Unlike the quiet Mr. Yu. G., he had a wide circle of friends, including
several mistresses. He spread the agent far and wide in the town. The agent
jumped easily from person to person, apparently through touching and
sexual contact. It was a fast spreader, and it could live easily in people. It passed through as many as sixteen generations of infection as it jumped
from person to person in Sudan. It also killed many of its hosts. While this is
not necessarily in the best interest of the virus, if the virus is highly
contagious, and can jump fast enough from host to host, then it does not
matter, really, what happens to the previous host, because virus can amplify
itself for quite a while, at least until it kills off much of the population of
hosts. Most of the fatal cases of Ebola Sudan can be traced back through
chains of infection to the quiet Mr. Yu. G. A hot strain radiated out of him
and nearly devastated the human population of southern Sudan. The strain
burned through the town of Nzara and reached eastward to the town of
Maridi, where there was a hospital.
It hit the hospital like a bomb. It savaged patients and snaked like chain
lightning out from the hospital through patients' families.
Apparently the medical staff had been giving patients injections with dirty
needles. The virus jumped quickly through the hospital via the needles, and
then it hit the medical staff. A characteristic of a lethal, contagious, and
incurable virus is that it quickly gets into the medical people. In some cases,
the medical system may intensify the outbreak, like a lens that focuses
sunlight on a heap of tinder.
The virus transformed the hospital at Maridi into a morgue. As it jumped
from bed to bed, killing patients left and right, doctors began to notice signs
of mental derangement, psychosis, depersonalization, zombie-like behavior.
Some of the dying stripped off their clothes and ran out of the hospital,
naked and bleeding, and wandered through the streets of the town, seeking
their homes, not seeming to know what had happened or how they had
gotten into this condition. There is no doubt that Ebola damages the brain
and causes psychotic dementia. It is not easy, however, to separate brain
damage from the effects of fear. If you were trapped in a hospital where
people dissolving in their beds, you might try to escape, and if you were a
bleeder and frightened, you might take off your clothes, and people might
think you had gone mad.
The Sudan strain was more than twice as lethal as Marburg virus – its case fatality rate was 50 percent. That is, fully half of the people who came down
with it ended up dying, and quickly. This was the same kind of fatality rate
as was seen with the black plague during the Middle Ages. If the Ebola Sudan virus had managed to spread out of central Africa, it might have
entered Khartoum in a few weeks, penetrated Cairo a few weeks after that,
and from there it would have hopped to Athens, New York, Paris, London,
Singapore – it would have gone everywhere on the planet. Yet that never
happened, and the crisis in Sudan passed away unnoticed by the world at
large. What happened in Sudan could be compared to the secret detonation
of an atomic bomb. If the human race came close to a major biological
accident, we never knew it.
For reasons that are not clear, the outbreak subsided, and the virus vanished.
The hospital at Maridi had been the epicenter of emergence. As the virus
ravaged the hospital, the surviving medical staff panicked and ran off into
the bush. It was probably the wisest thing to do and the best thing that could
have happened, because it stopped the use of dirty needles and emptied the
hospital, which helped to break the chain of infection.
There was another possible reason why the Ebola Sudan virus vanished. It
was exceedingly hot. It killed people so fast that they didn't have much time
to infect other people before they died.
Furthermore, the virus was not airborne. It was not quite contagious enough
to start a full-scale disaster. It traveled in blood, and the bleeding victim did
not touch very many other people before dying, and so the virus did not have
many chances to jump to a new host. Had people been coughing the virus
into the air ... it would have been a different story. In any case, the Ebola
Sudan virus destroyed a few hundred people in central Africa the way a fire
consumes a pile of straw – until the blaze burns out at the center and ends in
a heap of ash – rather than smoldering around the planet, as AIDS has done,
like a fire in a coal mine, impossible to put out. The Ebola virus, in its Sudan
incarnation, retreated to the heart of the bush, where undoubtedly it lives to
this day, cycling and cycling in some unknown host, able to shift its shape,
able to mutate and become a new thing, with the potential to enter the
human species in a new form.
TWO MONTHS AFTER the start of the Sudan emergence – the time was
early September 1976 – an even more lethal filovirus emerged five hundred
miles to the west, in a district of northern Zaire called Bumba Zone, an
ahead of tropical rain forest populated by scattered villages and drained by
the Ebola River. The Ebola Zaire strain was nearly twice as lethal as Ebola Sudan. It seemed to emerge out of the stillness of an implacable force
brooding on an inscrutable intention. To this day, the first human case of
Ebola Zaire has never been identified.
In the first days of September, some unknown person who probably lived
somewhere to the south of Ebola River perhaps touched something bloody.
It might have been monkey meat – people in that area hunt monkeys for
food – or it might have been the meat of some other animal, such as an
elephant or a bat. Or perhaps the person touched a crushed insect, or perhaps
he or she was bitten by a spider. Whatever the original host of the virus, it
seems that a blood-to-blood contact in the rain forest enabled the virus to
move into the human world. The portal into the human race may well have
been a cut on this unknown person's hand.
The virus surfaced in the Yambuku Mission Hospital, an upcountry clinic
run by Belgian nuns. The hospital was a collection of corrugated tin roofs
and whitewashed concrete walls sitting beside a church in the forest, where
bells rang and you heard a sound of hymns and the words of the high mass
spoken in Bantu. Next door, people stood in line at the clinic and shivered
with malaria while they waited for a nun to give them an injection of
medicine that might make them feel better.
The mission in Yambuku also ran a school for children. In later August, a
teacher from the school and some friends went on a vacation trip to the
northern part of Zaire. They borrowed a Land Rover from the mission to
make their journey, and they explored the country as they headed northward,
moving slowly along rutted tracks, no doubt getting stuck in the mud from
time to time, which is the way things go when you try to drive through
Zaire. The track was mostly a footpath enclosed by a canopy of trees, and it
was always in shadow, as if they were driving through Zaire. The track was
mostly a footpath enclosed by a canopy of trees, and it was always in
shadow, as if they were driving through a tunnel. Eventually they came to
the Ebola River and crossed it on a ferry barge and continued northward.
Near the Obangui River, they stopped at a roadside market, where the
schoolteacher bought some fresh antelope meat.
One of his friends bought a freshly killed monkey and put it in the back of
the Land Rover. Any of the friends could have handled the monkey or the
antelope meat while they were bouncing around in the Land Rover.
They turned back, and when the schoolteacher arrived home, his wife
stewed the antelope meat, and everyone in the family ate it. The following
morning he felt unwell, and so before he reported to his teaching job at the
school, he stopped off at the Yambuku Hospital, on the other side of the
church, to get an injection of medicine from the nuns.
At the beginning of each day, the nuns at Yambuku Hospital would lay out
five hypodermic syringes on a table, and they would use them to give shots
to patients all day long. They were using five needles a day to give
injections to hundreds of people in the hospital's outpatient and maternity
clinics. The nuns and staff occasionally rinsed the needles in a pan of warm
water after an injection, to get the blood off the needle, but more often they
proceeded from shot to shot without rinsing the needle, moving from arm to
arm, mixing blood with blood. Since Ebola virus is highly infective and
since as few as five or ten particles of the virus in a blood-borne contact can
start an extreme amplification in a new host, there would have been
excellent opportunity for the agent to spread.
A few days after schoolteacher received his injection, he broke with Ebola
Zaire. He was the first known case of Ebola Zaire, but he may well have
contracted the virus from a dirty needle during his injection at the hospital,
which means that someone else might have previously visited the hospital
while sick with Ebola virus and earlier in the day received an injection from
the same needle that was then used on the schoolteacher.
That unknown person probably stood in line for an injection just ahead of
the schoolteacher. That person would have started the Ebola outbreak in
Zaire. As in Sudan, the emergence of a life form that could in theory have
gone around the earth began with one infected person.
The virus erupted simultaneously in fifty-five villages surrounding the
hospital. First it killed people who had received injections, and then it
moved through families, killing family members, particularly women, who
in Africa prepare the dead for burial. It swept through the Yambuku
Hospital's nursing staff, killing most of the nurses, and then it hit the Belgian
nuns. The first nun to break with Ebola was a midwife who had delivered a
stillborn child. The mother was dying of Ebola and had given the virus to
her unborn baby. The fetus had evidently crashed and bled out inside the
mother's womb. The woman then aborted spontaneously, and the nun who assisted at this grotesque delivery came away from the experience with
blood on her hands. The blood of the mother and fetus was radiantly hot,
and the nun must have had a small break or cut on the skin of her hands. She
developed an explosive infection and was dead in five days.
There was a nun at the Yambuku Hospital who is known today as Sister
M.E. She became gravely ill with l'epidemie, or "the epidemic," as they had
begun to call it. A priest at Yambuku decided to try to take her to the city of
Kinshasa, the capital of Zaire, in order to get her better medical treatment.
He and another nun, named Sister E.R., drove Sister M.E. in a Land Rover
to the town of Bumba, a sprawl of cinder blocks and wooden shacks that
huddles beside the Congo River. They went to the airfield at Bumba and
hired a small plane to fly to Kinshasa, and when they reached the city, they
took Sister M.E. to Ngaliema Hospital, a private hospital run by Swedish
nurses, where she was given a room of her own.
There she endured her agonals and committed her soul to Christ.
EBOLA ZAIRE ATTACKS every organ and tissue in the human body
except skeletal muscle and bone. It is a perfect parasite because it transforms
virtually every part of the body into a digested slime of virus particles.
The seven mysterious proteins that, assembled together, make up the Ebola virus particle, work as a relentless machine, a molecular shark, and they
consume the body as the virus makes copies of itself. Small blood clots
begin to appear in the bloodstream, and the blood thickens and slows, and
the clots begin to stick to the walls of blood vessels. This is known as
pavementing, because the clots fit together in a mosaic. The mosaic thickens
and throws more clots, and the clots drift through the bloodstream into the
small capillaries, where they get stuck. This shuts off the blood supply to
various part of the body, causing dead spots to appear in the brain, liver,
kidneys, lungs, intestines, testicles, breast tissue (of men as well as women),
and all through the skin. The skin develops red spots, called petechiae,
which are hemorrhages under the skin. Ebola attacks connective tissue with
particular ferocity; it multiplies in collagen, the chief constituent protein of
the tissue that holds the organs together. (The seven Ebola proteins
somehow chew up the body's structural proteins.) In this way, collagen in
the body turns to mush, and the under layers of the skin die and liquefy. The
skin bubbles up into a sea of tiny white blisters mixed with red spots known as a maculopapular rash. The rash has been likened to tapioca pudding.
Spontaneous rips appear in the skin, and hemorrhagic blood pours from the
rips. The red spots on the skin grow and spread and merge to become huge,
spontaneous bruises, and he skin goes soft and pulpy, and can tear off if it is
touched with any kind of pressure. Your mouth bleeds, and you bleed
around your teeth, and you may have hemorrhages from the salivary
glands – literally every opening in the body bleeds, no matter how small.
The surface of the tongue turns brilliant red and then sloughs off, and is swallowed or spat out. It is said to be extraordinarily painful to lose the surface of one's tongue. The tongue's skin may be torn off during rushes of the black vomit. The back of the throat and the lining of the windpipe may also slough off, and the dead tissue slides down the windpipe into the lungs or is coughed up with sputum. Your heart bleeds into itself; the heart muscle softens and has hemorrhages into its chambers, and blood squeezes out of the heart muscle as the heart beats, and it floods the chest cavity. The brain becomes clogged with dead blood cells, a condition known as sludging of the brain. Ebola attacks the lining of the eyeball, and the eyeballs may fill up with blood: you may go blind.
Droplets of blood stand out on the eyelids: you may weep blood. The blood runs from your eyes down your cheeks and refuses to coagulate. You may have a hemispherical stroke, in which one whole side of the body is paralyzed, which is invariably fatal in a case of Ebola. Even while the body's internal organs are becoming plugged with coagulated blood, the blood that streams out of the body cannot clot; it resembles when being squeezed out of curds. The blood has been stripped of its clotting factors. If you put the runny Ebola blood in a test tube and look at it, you see that the blood is destroyed. Its red cells are broken and dead.
The blood looks as if it has been buzzed in an electric blender.
Ebola kills a great deal of tissue while the host is still alive.
It triggers a creeping, spotty necrosis that spreads through all the internal organs. The liver bulges up and turns yellow, begins to liquefy, and then it cracks apart. The cracks run across the liver and deep inside it, and the liver completely dies and goes putrid. The kidneys become jammed with blood clots and dead cells, and cease functioning. As the kidneys fail, the blood becomes toxic with urine. The spleen turns into a single huge, hard blood clot the size of a baseball. The intestines may fill up completely with blood. The lining of the gut dies and sloughs off into the bowels and is defecated along with large amounts of blood. In men, the testicles bloat up and turn black-and-blue, the semen goes hot with Ebola, and the nipples may bleed. In women, the labia turn blue, livid, and protrusive, and there may be massive vaginal bleeding. The virus is a catastrophe for a pregnant woman: the child is aborted spontaneously and is usually infected with Ebola virus, born with red eyes and a bloody nose.
Ebola destroys the brain more thoroughly than does Marburg, and Ebola victims often go into epileptic convulsions during the final stage.
The convulsions are generalized grand mal seizures – the whole body twitches and shakes, the arms and legs thrash around, and the eyes, sometimes bloody, roll up into the head. The tremors and convulsions of the patient may smear or splatter blood around. Possibly this epileptic splashing of blood is one of Ebola's strategies for success – it makes the victim go into a flurry of seizures as he dies, spreading blood all over the place, thus giving the virus a chance to jump to a new host – a kind of transmission through smearing.
Ebola (and Marburg) multiplies so rapidly and powerfully that the body's infected cells become crystal-like blocks of packed virus particles. These crystals are broods of virus getting ready to hatch from the cell. They are known as bricks. The bricks, or crystals, first appear near the center of the cell and then migrate toward the surface.
As a crystal reaches a cell wall, it disintegrates into hundreds of individual virus particles, and the bloodlings push through the cell wall like hair and float away in the bloodstream of the host. The hatched Ebola particles cling to cells everywhere in the body, and get inside them, and continue to multiply. It keeps on multiplying until areas of tissue all through the body are filled with crystalloids, which hatch, and more Ebola particles drift into the bloodstream, and the amplification continues inexorably until a droplet of host's blood can contain a hundred million individual virus particles.
After death, the cadaver suddenly deteriorates: the internal organs, having been dead or partially dead for days, have already begun to dissolve, and a sort of shock-related meltdown occurs. The corpse's connective tissue, skin, and organs, already peppered with dead spots, heated by fever, and damaged by shock, begin to liquefy, and the fluids that leak from the cadaver are saturated with Ebola-virus particles.
WHEN IT WAS all over, the floor, chair, and walls in Sister M.E's hospital room were stained with blood. Someone who saw the room told me that after they took her body away for burial (wrapped in many sheets), no one at the hospital could bear to go into the room to clean it up. The nurses and doctors didn't want to touch the blood on the walls and were frankly fearful of breathing the air in the room, too. So the room was closed and locked, and remained that way for days. The appearance of the nun's hospital room after her death may have raised in some minds one or two question about the nature of the Supreme Being, or, for persons not inclined to theology, the blood on the walls may have served as a reminder of the nature of Nature.
No one knew what had killed the nun, but clearly it was a replicating agent, and the signs and symptoms of the disease were not easy to consider with a calm mind. What also did not lead to calm thoughts were rumors coming out of the jungle to the effect that the agent was wiping out whole villages upriver on the Congo. These rumors were not true. The virus was hitting families selectively, but no one understood this because the flow of news coming from upriver was being choked off.
Doctors at the hospital in Kinshasa examined the nun's case and began to suspect that she might have died of Marburg or a Marburg -like agent.
Then Sister E.R., the nun who had traveled with Sister M.E. during the drive to Bumba and the plane flight to Kinshasa, broke with l'epidémie. They put her in a private room at the hospital, where she began to die with the same signs and symptoms that had preceded Sister M.E.'s death.
There was a young nurse at the Ngaliema Hospital named Mayinga N. (Her first name was Mayinga and her last name is given as N.) Nurse Mayinga had been caring for Sister M.E. when the nun had died in the bloodstained room. She may have been splattered with the nun's blood or with black vomit. At any rate, Nurse Mayinga developed a headache and fatigue. She knew she was becoming sick, but she did not want to admit to herself what it was. She came from a poor but ambitious family, and she had received a scholarship to go to college in Europe. What worried her was the possibility that if she became ill, she would not be allowed to travel abroad. When the headache came upon her, she left her job at the hospital and disappeared. She dropped out of sight for two days. During that time, she went into the city, hoping to get her travel permits arranged before she became visibly sick. On the first day of her disappearance – the date was October 12, 1976 – she spent a day waiting in lines at the offices of the Zairean foreign ministry, trying to get her papers straight.
The next day, October 13, she felt worse, but instead of reporting to work, again she went into the city. This time, she took a taxi to the largest hospital in Kinshasa, the Mama Yemo Hospital. By now, as her headache became blinding and her stomach pain increased, she must have been terribly frightened. Why didn't she go to the Ngaliema Hospital to seek treatment where she worked and where the doctors would have taken care of her? It must have been a case of psychological denial. She did not want to admit, even to herself, that she had been infected. Perhaps she had a touch of malaria, she hoped. So she went to Mama Yemo Hospital, the hospital of last resort for the city's poor, and spent hours waiting in a casualty ward jammed with ragged people and children.
I can see her in my mind's eye – Nurse Mayinga, the source of the virus in the United States Army's freezers. She was a pleasant, quiet, beautiful young African woman, about twenty years old, in the prime of her life, with a future and dreams, hoping somehow that what was happening to her could not be happening. They say that her parents loved her dearly, that she was the apple of their eye. Now she is sitting in the casualty ward at Mama Yemo among the cases of malaria, among the large-bellied children in rags, and no one is paying any attention to her because all she has is a headache and red eyes. Perhaps the fact that she is crying has made her eyes red. A doctor gives her a shot for malaria and tells her that she should be in quarantine for her illness. But there is no room in the quarantine ward at Mama Yemo Hospital; so she leaves the hospital and hails another taxi. She tells the driver to take her to another hospital, to University Hospital, where perhaps the doctors can treat her. But when she arrives at University Hospital, the doctors can't seem to find anything wrong with her, except for possibly some sign of malaria. Her headache is getting worse. She is sitting in the waiting room of this hospital, and as I try to imagine her there, I am almost certain she is crying. Finally she does the only thing left for her to do. She returns to Ngaliema Hospital and asks to be admitted as a patient. They put her in a private room, and there she falls into lethargy, and her face freezes into a mask.
News of the virus and what it did to people had been trickling out of the forest, and now a rumor that a sick nurse had wandered around Kinshasa for two days, having face-to-face contact with many people in crowded rooms and public places, caused a panic in the city. The news spread first along the mission grapevine and through government employees and among the diplomats at cocktail parties, and finally the rumors began to reach Europe. When the story reached the offices of the World Health Organization in Geneva, the place went into a full-scale alert. People who were there at the time said that you could feel fear in the hallways, and the director looked like a visibly shaken man. Nurse Mayinga seemed to be a vector for an explosive claim of lethal transmission in a crowded third-world city with a population of two million people. Officials at the WHO began to fear that Nurse Mayinga would become the vector for a world-wide plague. European governments contemplated blocking flights from Kinshasa. The fact that one infected person had wandered around the city for two days when she should have been isolated in a hospital room began to look like a species threatening event.
President Mobutu Sese Seko, the maximum leader of Zaire, sent his army into action. He stationed soldiers around Ngaliema Hospital with orders to let no one enter or leave except doctors. Much of the medical staff was not under quarantine inside the hospital, but the soldiers made sure that the quarantine was enforced. President Mobutu also ordered army units to seal off Bumba Zone with roadblocks and to shoot anyone trying to come out. Bumba's main link with the outside world was the Congo River.
Captains of riverboats had heard about the virus by this time, and they refused to stop their boats anywhere along the length of the river in Bumba, even though people beseeched them from the banks. Then all radio contact with Bumba was lost. No one knew what was happening upriver, who was dying, what the virus was doing. Bumba had dropped off the face of the earth into the silent heart of darkness.
AS THE FIRST nun at Ngaliema Hospital, Sister M.E., lay dying, her doctors had decided to give her a so-called agonal biopsy. This is a rapid sampling of tissue, done close to the moment of death instead of a full autopsy. She was a member of a religious order that prohibited autopsies, but the doctors very much wanted to know what was replicating inside her.
As the terminal shock and convulsions came over her, they inserted a needle into her upper abdomen and sucked out a quantity of liver. Her liver had begun to liquefy, and the needle was large. A fair amount of the nun's liver traveled up the needle and filled a biopsy syringe.
Possibly it was during this agonal biopsy that her blood squirted on the walls. The doctors also took some samples of blood from her arm and put it in glass tubes. The nun's blood was precious beyond measure, since it contained the unknown hot agent.
The blood was flown to a national laboratory in Belgium and to the England natural laboratory, the Microbiological Research Establishment at Porton Down, in Wiltshire. Scientists at both labs began racing to identify the agent. Meanwhile, at the Centers for Disease Control in Atlanta, Georgia – the C.D.C. – scientists were feeling left out, and were still scrambling to get their hands on a little bit of the nun's blood, making telephone calls to Africa and Europe, pleading for the samples.
There is a branch of the C.D.C. that deals with unknown emerging viruses. It's called the Special Pathogens Branch. In 1976, at the time of the Zaire outbreak, the branch was being run by a doctor named Karl M. Johnson, a virus hunter whose home terrain had been the rain forests of Central and South America. (He is not related to Gene Johnson, the civilian virus hunter, or to Lieutenant Colonel Tony Johnson, the pathologist.) Karl Johnson and his C.D.C. colleagues had heard almost nothing about the occurrences upriver in Zaire – all they knew was that people in Zaire were dying of a "fever" that had "generalized symptoms" – no details had come in from the bush or from the hospital where the nun had just died. Yet it sounded like a bad one. Johnson telephoned a friend of his at the English lab, in Porton Down, and reportedly said to him, "If you've got any little dregs to spare of that nun's blood, we'd like to have a look at it." The Englishman agreed to send it to him, and what he received was literally dregs.
The nun's blood arrived at C.D.C. in glass tubes in a box lined with dry ice. The tubes had cracked and broken during shipment, and raw, rotten blood had run around inside the box. A C.D.C. virologist named Patricia Webb – who was then married to Johnson – opened the box. She found that the package was sticky with blood. The blood looked like tar. It was black and gooey, like Turkish coffee. She put on rubber gloves, but other than that, she did not take any special precautions in handling the blood. Using some cotton balls, she managed to dab up some of the black stuff, and then by squeezing the cotton between her fingertips, she collected a few droplets of it, just enough to begin testing it for viruses.
Patrica Webb put some of the black blood droplets into flasks of monkey cells, and pretty soon the cells got sick and began to die – they burst. The unknown agent could infect monkey cells and pop them.
Another C.D.C. doctor who worked on the unknown virus was Frederick A. Murphy, a virologist who had helped to identify Marburg virus. He was and is one of the world's leading electron-microscope photographers of viruses. (His photographs of viruses have been exhibited in art museums.) Murphy wanted to take a close look at those dying cells to see if he could photograph a virus in them. On October 13 – the same day Nurse Mayinga was sitting in the waiting rooms of hospitals in Kinshasa – he placed a droplet of fluid from the cells on a small screen and let it dry, and he put it in his electron microscope to see what he could see.
He couldn't believe his eyes. The sample was jammed with virus particles. The dried fluid was shot through with something that looked like string. His breath stopped in his throat. He thought, Marburg. He believed he was looking at Marburg virus.
Murphy stood up abruptly, feeling strange. The lab where he had prepared these samples – that lab was hot. The lab was as hot as hell. He went out of the microscope room, closing the door behind him, and hurried down a hallway to the laboratory where he had worked with the material.
He got a bottle of Clorox bleach and scrubbed the room from top to bottom, washing countertops and sinks, everything, with bleach. He really scoured the place. After he had finished, he found Patricia Webb and told her what he had seen in his microscope. She telephoned her husband and said to him, "Karl, you'd better come quick to the lab. Fred has looked at a specimen, and he's got worms."
Staring at the worms, they tried to classify the shapes. They saw snakes, pigtails, branchy, forked things that looked like the letter Y, and they noticed squiggles like a small g, and bends like the letter U, and loopy 6s. They also noticed a classic shape, which they began calling the shepherd's crook. Other Ebola experts have taken to calling this loop the eyebolt, after a bolt of the same name that can be found in a hardware store. It could also be described as a Cheerio with a long tail.
The next day, Patrica Webb ran some tests on the virus and found that it did not react to any of the tests for Marburg or any other known virus. Therefore, it was an unknown agent, a new virus. She and her colleagues had isolated the strain and shown that it was something new.
They had earned the right to name the organism. Karl Johnson named it Ebola.
Karl Johnson has since left the C.D.C., and he now spends a great deal of his time fly-fishing for trout in Montana. He does consulting work on various matters, including the design of pressurized hot zones. I learned that he could be reached at a fax number in Big Sky, Montana, so I sent him a fax. In it, I said that I was fascinated by Ebola virus. My fax was received, but there was no reply. So I waited a day and then sent him another fax. It fell away into silence. The man must have been too busy fishing to bother to answer. After I had given up hope, my fax machine suddenly emitted this reply:
Mr. Preston:
Unless you include the feeling generated by gazing into the eyes of a waving confrontational cobra, "fascination" is not what I feel about Ebola. How about shit scared?"
Two days after he and his colleagues isolated Ebola virus for the first time, Karl Johnson headed for Africa in the company of two other C.D.C. doctors, along with seventeen boxes of gear, to try to organize an effort to stop the 73 virus in Zaire and Sudan (the outbreak in Sudan was still going on). They flew first to Geneva, to make contact with the World Health Organization, where they found that the WHO knew very little about the outbreaks. So the C.D.C. doctors organized their equipment and packed more boxes, getting ready to go to the Geneva airport, from where they would fly to Africa. But then, at the last possible moment, one of C.D.C. doctors panicked. It is said he was the doctor assigned to go to Sudan, and it is said he was afraid to proceed any farther. It was not an unusual situation. As Karl Johnson explained to me, "I've seen young physicians run from these hemorrhagic viruses, literally. They're unable to work in the middle of an outbreak. They refuse to get off the plane."
Johnson, one of the discoverers of Ebola virus, preferred to talk about these events while fly-fishing. ("We've got to keep our priorities straight," he explained to me.) So I flew to Montana and spent a couple of days with him fishing for brown trout on the Bighorn River. It was October, the weather had turned clear and warm, and the cottonwood trees along the banks were yellow and rattled in a south wind. Standing waist-deep in a mutable slick of the river, wearing sunglasses, with a cigarette hanging from the corner of his mouth and a fly rod in his hand, Johnson ripped his line off the water and laid a cast upstream. He was a lean, bearded man, with a soft voice that one had to listen for in the wind. He is a great figure in the history of virus hunting, having discovered and named some of the most dangerous life forms on the planet.
"I'm so glad nature is not benign," he remarked. He studied the water, took a step downstream, and placed another cast. "But on a day like today, we can pretend nature is benign. All monsters and beasts have their benign moments."
"What happened in Zaire?" I asked.
"When we got to Kinshasa, the place was an absolute mad house," he said. "There was no news coming out of Bumba, no radio contact. We knew it was bad in there, and we knew we were dealing with something new. We didn't know if the virus could be spread by droplets in the air, something like influenza. If Ebola had spread easily through the air, the world would be a very different place today."
"How so?"
"There would be a lot fewer of us. It would have been exceedingly difficult to confirm that virus if it had any major respiratory component.
I did figure that if Ebola was the Andromeda strain – incredibly lethal and spread by droplet infection – there wasn't going to be any safe place in the world anyway. It was better to be working at the epicenter than to get the infection at the London opera."
"Are you worried about a species-threatening event?"
He stared at me, "What the hell do you mean by that?"
"I mean a virus that wipes us out."
"Well, I think it could happen. Certainly it hasn't happened yet. I'm not worried. More likely it would be a virus that reduces us by ninety percent."
"Nine out of ten human killed? And you're not bothered."
A look of mysterious amusement crossed his face. "A virus can be useful to a species by thinning it out," he said.
A scream cut the air. It sound nonhuman. He took his eyes off the water and looked around. "Hear that pheasant? That's what I like about the Bighorn River," he said.
"Do you find viruses beautiful?"
"Oh, yeah," he said softly. "Isn't true that if you stare into the eyes of a cobra, the fear has another side to it? The fear is lessened as you begin to see the essence of the beauty. Looking at Ebola under an electron microscope is looking at a gorgeously wrought ice castle. The thing is cold. So totally pure."
Karl Johnson became the chief of an international WHO team that gathered in Kinshasa.
THE OTHER C.D.C. doctor, Joel Breman, who had flown with Johnson to Zaire, became a member of a field exploration team that boarded an aircraft bound for the interior to see what was going on in Bumba. The airplane was a C-130 Buffalo troop-transport, an American-made military aircraft that belonged to the Zaire Air Force. It happened to be President Mobutu's private plane, equipped with leopard-skin seats, folding beds, and a wet bar, a sort of flying presidential palace that ordinarily took the president and his family on vacations to Switzerland, but now it carried the WHO team into the hot zone, following the Congo River north by east.
They sat on the leopard-skin seats and stared out the windows at endless tracts of rain forest and brown river, a featureless blanket broken by the occasional gleam of an oxbow lake or a cluster of round huts strung like beads on a barely visible road or footpath. As he leaned against the window and watched the terrain unfold into the heart of Africa, Breman became terrified of coming to earth. It was safe in the air, high above the immeasurable forest, but down there ... It began to dawn on him that he was going to Bumba to die. He had recently been assigned to Michigan as a state epidemiologist, and suddenly he had been called to Africa. He had left his wife back home in Michigan with their two children, and he began to suspect that he would never see them again. He had brought an overnight bag with a toothbrush, and he had managed to pack a few paper surgical masks and some gowns and rubber gloves into the bag. He did not have proper equipment for handling a hot agent. The Buffalo descended, and the town of Bumba appeared, a rotting tropical port spread out along the Congo River.
The Buffalo landed at an airstrip outside the town. The plane's Zaire crew was terrified, afraid to breathe the air, and they left the propellers idling while they showed the doctors down the gangway and heaved their bags out after them. The doctors found themselves standing in the backwash of the Buffalo as it accelerated to take off.
In the town, they met with the governor of Bumba Zone. He was a local politician, quite distraught. He had found himself in deep waters, in over his head. "We are in a bad way," he told the doctors. "We have not been able to get salt or sugar." His voice trembled on the edge of weeping as he added, "We have not even been able to get beer."
A Belgian doctor on the team knew how to handle this situation.
With a dramatic flourish, he placed a black airline pilot's bag on the table. Then he turned the bag upside down, and wads of currency slapped out, making an impressive heap. "Governor, perhaps this will make things a little better." he said.
"What are you doing?" Breman said to the Belgian.
The Belgian shrugged. "Look, this is the way things are done here."
The governor scooped up the money and pledged his full cooperation together with all the extensive resources of government at his disposal – and he loaned them two Land Rovers.
They pushed north toward the Ebola River.
It was the rainy season, and the "road" was a string of mud holes cut by running streams. Engines howling, wheels spinning, they proceeded through the forest at the pace of a wall, in continual rain and oppressive heat. Occasionally they came to villages, and at each village they encountered a roadblock of fallen trees. Having had centuries of experience with the smallpox virus, the village elders had instituted their own methods for controlling the virus, according to their received wisdom, which was to cut their villages off from the world, to protect their people from a raging plague. It was reverse quarantine, an ancient practice in Africa, where a village bars itself from strangers during a time of disease, and drives away outside who appear.
"Who are you? What are you doing?" they shouted to the Land Rovers from behind a barrier of trees.
"We are doctors! We are coming to help!"
Eventually the people would clear away the trees, and the team would proceed deeper into the forest. In a long and desperate day of travel, they penetrated fifty miles away from the Congo River, and finally, toward evening, they came to a row of round, hatched African houses. Beyond the houses stood a white church in the middle of the forest. Around the church, there were two soccer fields, and in the middle of one field they noticed a heap of burned mattresses. Two hundred yards farther on, they came to the Yambuku Mission Hospital, a complex of low, whitewashed buildings made of concrete, with corrugated tin roofs.
The place was as silent as a tomb and appeared to be deserted.
The beds were iron or wooden frames without mattresses – the blood-soaked mattresses had been burned in the soccer field – and the floors were clean, spotless, rinsed. The team discovered three surviving nuns and one priest, along with a few devoted African nurses. They had cleaned up the mess after the virus had wiped out everyone else, and now they were busy fogging the rooms with insecticide, in the hope that it might somehow disperse the virus. One room in the hospital had not been cleaned up. No one, not even the nuns, had the courage to enter the obstetric ward. When Joel Breman and the team went in, they found basins of foul water standing among discarded, bloodstained syringes. The room had been abandoned in the middle of childbirths, where dying mothers had aborted fetuses infected with Ebola. The team had discovered the red chamber of virus queen at the end of the earth, where the life form had amplified through mothers and their unborn children.
The rains continued all day and night. Around the hospital and the church stood the beautiful ferocious trees, a complex of camphor's and teaks. Their crowns entwined and crisscrossed and whispered with rain, and bowed and shifted as troops of monkeys passed through them like currents of wind, leaping from crown to crown, crying their untranslatable cries. The next day, the doctors set out deeper into the forest in their Land Rovers, and they made contact with infected villages, where they found people dying in huts. Some of the victims had been put into isolation huts on the edge of the village-an old African technique for dealing with smallpox. Some of the huts where people had died had been burned down. Already the virus seemed to be petering out, and most of the people who were going to die were already dead, the virus having echoed so swiftly through Bumba. A wave of emotion rolled over Joel Breman as he realized, with the clarity of a doctor who suddenly sees into the heart of things, that the victims had received the infection from the hospital.
The virus had taken root with the nuns and had done its work among those who had sought help from them. In one village, he examined a man dying of 78 Ebola. The man sat in a chair, holding his stomach and leaning forward with pain, and blood streamed around his teeth.
They tried to reach Kinshasa by radio, to tell Karl Johnson and the others that the epidemic had already peaked. A week later, they were still trying to make radio contact, but they could not get through. They traveled back to the town of Bumba and waited by the river. One day an airplane droned overhead. It circled the town once and touched down, and they ran for it.
AT THE NGALIEMA HOSPITAL in Kinshasa, Nurse Mayinga had been put into a private room, which was accessible through a kind of empty room, a gray zone, where the nurses and staff were supposed to put on bio-protective gear before they entered. Mayinga was cared by a South African doctor named Margaretha Isaacson, who at first wore a military gas mask, but it became increasingly uncomfortable in the tropical heat. She thought to herself, I can't bear it. I'll be surprised if I come out of this alive anyway. That made her think about her own children. She thought, My children are grown up, they are no great responsibility. And she removed her mask and treated the dying girl face-to-face.
Dr. Isaacson did everything she could to save Mayinga, but she was as helpless before the agent as medieval doctors had been in the face of the black plague. ("This was not like AIDS," she would later recall. "AIDS is a child's play compared with this.") She gave Nurse Mayinga ice cubes to suck on, which helped to ease the pain in her throat, and she gave her Valium to try to stave off her apprehension of what lay ahead.
"I know I am dying," Mayinga said to her.
"That's nonsense. You are not going to die." Dr. Isaacson replied.
When Mayinga's bleeding began, it came from her mouth and nose.
It never came in a rush, but the blood dripped and ran and would not stop and would not clot. It was a hemorrhagic nose bleed, the kind that does not stop until the heart stops beating. Eventually Dr. Isaacson gave her three transfusions of whole blood to replace what she lost in nosebleeds.
Mayinga remained conscious and despondent until the end. In the final stage, her heart developed a galloping beat. Ebola had entered her heart.
Mayinga could feel her heart going blubbery inside her chest, and it frightened her unspeakably. That night, she died of a heart attack.
Her room was contaminated with blood, and there was also the question of the two nuns' rooms, both of which were still locked and bloodstained. R. Isaacson said to the staff, "I won't be of much use to you now," and she got a bucket and mop and washed the rooms.
Medical teams fanned out into Kinshasa and managed to locate thirty-seven people who had face-to-face contact with Mayinga during the time when she had wandered around the city. They set up two biocontainment pavilions at the hospital and shut the people up for a couple of weeks. They wrapped like cadavers of the nuns an Nurse Mayinga in sheets soaked in chemicals, then double-bagged the mummies in plastic and put each one in an airtight coffin which a screw-down lid, and held the funeral services at the hospital, under the watch of doctors.
Karl Johnson, having heard nothing from the team of doctors upriver in Bumba, wondered if they were dead, and assumed that the virus was about to go on a burn through the city. He organized a floating hospital ship and had it moored in the Congo River. It was an isolation ship for doctors. The city would be the hot zone, and the floating ship would be the gray area, the place of refuge for the doctors.
Approximately a thousand Americans were living in Zaire at the time. In the United States, the Amy's Eighty-second Airborne Division went on alert and prepared to evacuate the Americans by air as soon as the first Ebola cases started popping up in the city. But to the strange and wonderful relief of Zaire and the world, the virus never went on a burn through the city. It subsides on the headwaters of the Ebola River and went back to its hiding place in the forest. The Ebola agent seemed not to be contagious in face-toface contacts. It did not seem to be able to travel through the air. No one caught the virus from Nurse Mayinga, even though she had been in close contact with at least thirty-seven people. She had shared a bottle soda pop with someone, and not even that person became ill. The crisis passed.
AS WITH EBOLA, the secret hiding place of the Marburg agent was unknown.
After erupting in Charles Monet and Dr. Shem Musoke, Marburg dropped out of sight, and no one could say where it had gone. It seemed to vanish off the face of the earth, but viruses never go away, they only hide, andMarburg continued to cycle in some reservoir of animals or insects in Africa.
On the second of day of September 1987, around suppertime, Eugene Johnson, the civilian biohazard expert attached to USAMRIID, stood in a passenger-arrival area outside the customs gates at Dulles International Airport, near Washington. He was waiting for a KLM flight from Amsterdam, which carried a passenger who had come from Kenya. A man with a duffle bag passed through customs, and he and Johnson nodded to each other.
("I'm going to leave this person's name out of it. Let's just say he was someone I knew, someone I trust." Johnson explained to me). The man laid down the duffle bag at Johnson's feet, unzipped it, and pulled out a wad of bath towels wrapped around something. Pulling off the towels, he revealed an unmarked cardboard box wound with tape. He handed the box to Johnson. They had little to say to each other. Johnson carried the box out of the terminal building, put it in the trunk of his car, and drove to the Institute. The box held blood serum from a ten-year-old Danish boy who will be called Peter Cardinal. He had died a day or so earlier at Nairobi Hospital with a combination of extreme symptoms that suggested an unidentified Level 4 virus.
As he drove to the Institute, Johnson wondered just what he was going to do with the box. He was inclined to sterilize its contents in an oven and then incinerate it. Just cook it and burn it, and forget it.
Most of the samples that came into the Institute – and samples of blood and tissue arrived constantly from all parts of the world – contained nothing unusual, no interesting viruses. In other words, most of the samples were false alarms. Johnson wasn't sure he wanted to take the time to analyze this boy's blood serum, if, in all probability, nothing would be found in it. By the time he pulled into the gates of Fork Detrick, he had decided to go ahead. He knew the work would keep him up most of the night, but it had to be done immediately, before the blood serum deteriorated.
Johnson put on a surgical scrub suit and rubber gloves, and carried the box into the Level 3 staging area of the Ebola suite, where he opened the box, revealing a mass of foam peanuts. Out of the peanuts he fished a metal cylinder sealed with tape and marked with a biohazard symbol. Along the wall of the staging area was a row of stainless-steel cabinets with rubber gloves protruding into them. They were Biosafety Level 4 cabinets. They could be sealed off from the outside world while you handled a hot agent inside them with the rubber gloves. These cabinets were similar in design to the safety cabinets that are used to handling nuclear-bomb parts. Here the cabinets were designed to keep human beings from coming into direct contact with Nature. Johnson unscrewed some wing nuts and opened a door in the cabinets, and placed the metal cylinder inside. He closed and tightened the door.
Next, he put his hands into the gloves, picked up the cylinder and, looking through a window to see what he was doing, peeled the tape off the cylinder. The tape stuck to his rubber gloves, and he couldn't get it off. Damn! he swore to himself. It was now eight o'clock at night, and he would never get home. Finally he got the cylinder open.
Inside it was a wad of paper towel soaked in bleach. He pulled apart the wad and found a Ziploc bag. It contained a couple of plastic tubes with screw tops. He unscrewed them and shook out two very small plastic vials containing golden liquid: Peter Cardinal's blood serum.
The boy's mother and father worked for a Danish relief organization in Kenya, and lived in a house in the town of Kisumu, on Lake Victoria. Peter had been a student at a boarding school in Denmark. That August, a few weeks before he died, he had gone to Africa to visit his parents and his older sister. She was a student at a private school in Nairobi. She and Peter were very close, and while Peter was visiting his family in Kenya, the two young people spent most of their time together – brother and sister, best friends.
The Cardinal family went on vacation after Peter's arrival, and traveled by car through Kenya – his mother and father wanted to show him the beauty and sweetness of Africa. They were visiting Mombasa, staying in a hotel by the sea, when Peter developed red eyes. His parents took him to the hospital, where the doctors examined him an concluded that he had come down with malaria. His mother did not believe it was malaria. She began to perceive that her son was dying, and she became frantic. She insisted that he be taken to Nairobi for treatment. The Flying Doctors, an air-ambulance service, picked him up, and he was rushed to Nairobi Hospital, where he came under care of Dr. David Silverstein, who had also taken care of Dr. Musoke after Charles Monet had spewed the black vomit into Musoke's eyes.
"PETER CARDINAL WAS a blond-haired, blue-eyed guy, a tall, thin guy, a fit-looking ten-year-old," Dr. Silverstein recalled as we drank coffee and tea at a table in the shopping mall near his house outside Washington. A small girl sitting burst into wails, and her mother hushed her. Crowds of shoppers passed by our table. I kept my eyes on Dr. Silverstein's face – steel-rimmed glasses, mustache, eyes that gazed into space – as he recalled the unusual death he had seen, which he spoke of a matter-of-fact way. "When Peter came to me, he was febrile, but he was very with it, very alert and communicative. We gave him an X-ray. His lungs were fluffy."
A kind of watery mucus had begun to collect in the boy's lungs, which caused him difficulty in breathing. "It was a typical ARDS picture – acute respiratory distress syndrome – like early pneumonia," Dr. Silverstein said.
"Shortly afterward, he started turning bluish on it. He had blue in his fingertips. Also, he had little red spots. I had everybody glove up before they handled him. We suspected he had Marburg, but we didn't have the paranoia we had with Dr. Musoke. We just took precautions. In twenty-four hours, he was on a respirator. We noted that he bled easily from puncture sites, and he had deranged liver functions. The small red spots became large, spontaneous bruises. He turned black-and-blue. Then his pupils dilated up on us. That was a sign of brain death. He was bleeding around the brain."
He swelled up, and his filled with pockets of blood. In some places, the skin almost separated from the underlying tissue. This happened during the last phase, while he was on a respirator. It is called third spacing. If you bleed into the first space, you bleed into your lungs. If you bleed into the second space, you bleed into your stomach and intestines. If you bleed into the third space, you bleed into the space between the skin and the flesh. The skin puffs up and separates from the flesh like a bag. Peter Cardinal had bled out under his skin.
THE MORE ONE contemplates the hot viruses, the less they look like parasites and the more they begin to look like predators. It is a characteristic of a predator to become invisible to its prey during the quiet and sometimes lengthy stalk that precedes an explosive attack. The savanna grass ripples on the plains, and the only sound in the air is the sound of African doves calling from acacia trees, a pulse that goes on through the heat of the day and never slows and never ends. In the distance, in the flickering heat, in the immense distance, a herd of zebras gaze. Suddenly from the grass comes a streak of movement, and a lion is among them and hangs on a zebra's throat. The zebra gives out a barking cry, choked off, and the two interlocked beings, the predator and the prey, spin around in a dance, until you lose sight of the action in a billow of dust, and the next day the bones have a surface of flies. Some of the predators that feed on humans have lived on the earth for a long time, far longer than the human race, and their origins go back, it seems, almost to the formation of the planet. When a human being is fed upon and consumed by one of them, especially in Africa, the event is telescoped against horizons of space and time, and takes on a feeling of immense antiquity.
Peter Cardinal's parents and sister were stunned as they watched him being slowing torn apart by an invisible predator. They could not comprehend his suffering or reach him to give him comfort. As the blood poured into his third space, his eyes remained open and dilated, staring, bloody, deep, dark, and bottomless. They didn't know if he could see them, and they couldn't tell what he saw or thought or felt behind the open eyes. The machines hooked up to his scalp were showing flatlines in his brain. There was little electrical activity in his brain, but now and then the flatlines gave a spooky twitch, as if something continued to struggle inside the boy, some destroyed fragment of his soul.
They had to make a decision about whether to turn off the respirator. Dr. Silverstein said to them, "We're much better off not letting him survive, because of brain death."
"If they had only brought him in sooner from Mombasa," the mother said.
"I'm sorry, but that would not have helped. There was nothing that anyone could have done," Silverstein replied to her. "He was doomed from the beginning."
WORKING WITH HIS hands in the rubber gloves protruding into the cabinets, Gene Johnson took a little bit of the boy's blood serum and dropped it into flasks that contained living cells from a monkey. If anything lived in Peter Cardinal's blood, it might begin to replicate in the monkey cells. Then Johnson went home to get some sleep. The procedure had taken him until three o'clock in the morning to finish.
In the following days, Johnson watched the flasks to see if there were any changes in the monkey cells. He saw that they were bursting and dying. They were infected with something. The Cardinal strain was definitely a hot agent – it killed the cells in vast numbers, and it killed them fast.
Now for the next stage of the virus isolation. He drew off a little bit of fluid from the flasks and injected it into three rhesus monkeys, to infect them with the Cardinal agent. Two of the monkeys died and the third animal went into borderline shock, but somehow pulled through and survived. So the Cardinal agent was viciously hot, a fast replicator, and it could kill monkeys. "I knew god-damned well we had Marburg," Johnson would later say to me.
He took some of the Cardinal strain and injected it into guinea pigs to see if it would infect them. It killed them like flies. Not only that, the testicles of the males swelled up to the size of golf balls and turned purple. The Cardinal strain was a sophisticated organism that knew what they wanted. It could multiply in many different kinds of meat. It was an invasive life form, devastating and promiscuous. It showed a kind of obscenity you see only in nature, an obscenity so extreme that it dissolves imperceptibly into beauty. It made a living somewhere in Africa. What made it particularly interesting was that it multiplied easily in various species, in monkeys, humans, guinea pigs. It was extremely lethal in these species, which meant that its original host was probably not monkeys, humans or guinea pigs but some other animal or insect that it did not kill. A virus does not generally kill its natural host. The Marburg virus was a traveler: it could jump species; it could break through the lines that separate one species from another, and when it jumped into another species, it could devastate the species. It did not know boundaries. It did not know what humans are; or perhaps you could say that it knew only too well what humans are: it knew that humans are meat.
As soon as he isolated the Cardinal strain and confirmed that it was Marburg, Johnson turned his attention to the question of where and how Peter Cardinal might have become infected. Where had that kid been? What had he been doing to get himself infected? Exactly where had he traveled?
These questions haunted Johnson. He had been trying to find the secret reservoirs of the thread viruses for years.
He telephoned a friend and colleague in Kenya named Dr. Peter Turkei, who was a scientist at the Kenya Medical Research Institute in Nairobi. "We know this is Marburg," Gene said to him. "Can you get a history of the kid? Find out where he was and what he did?"
Dr. Tukei said he would locate the parents and interview them.
A week later, Gene's telephone rang. It was Dr. Tukei on the line.
"You know where that kid was?" he said. "He was in Kitum Cave on Mount Elgon."
Gene felt a prickling sensation on his scalp. The paths of Charles Monet and Peter Cardinal had crossed at only one place on earth, and that was inside Kitum Cave. What had they done in the cave? What had they found in there? What had they touched? What had they breathed? What lived in Kitum Cave?
He was wearing sunglasses. He placed his large elbows on the table, took off his sunglasses, and rubbed his eyes. He was six foot two, maybe two hundred and fifty pounds. His eyes were brown and set deep in his bearded face, and there were dark circles under the lower lids. He looked tired.
"So Peter Tukei got on the phone to tell me that the boy had visited Kitum Cave," Johnson said. "I still get chills when I think about it. A few weeks later, I flew to Nairobi, and I talked with David Silverstein, the kid's doctor. Peter Tukei was with me. Then we went everyplace in Kenya the kid went, even to his house. His parents had a nice house in Kisumu, near Lake Victoria. It was a stucco house with a wall around it, and there was a cook and groundskeepers and a driver. The house was clean and neat, open and whitewashed. We saw that there was a rock hyrax living on the roof. It was a pet, and it lived in the gutters.
There were a couple of storks, and there were rabbits and goats and all kinds of birds. I didn't see any bats around this house."
He paused, thinking. No one else was around. A few ducks swam in the pond. "I was really nervous about talking with the parents," he said.
"See, I am a field person. My wife and I don't have children. I'm not the kind of a guy who can console a mother, plus I work in the U.S. military. I had no idea how to talk to them. I tried to put myself in their place, and I remembered how I felt when my father died. I let them talk about their son, Peter Cardinal and his sister had been inseparable from the moment he arrived in Kenya. The kids had spent the whole time together, doing everything together. So what was the difference in behavior? Why did Peter Cardinal get the virus but not his sister? There was one difference in their behavior. The parents told me a story about the rocks in the cave. They told me their kid was an amateur geologist.
There was this issue: did he cut his hand on any crystals in the cave? We went over that possibility with the parents, Peter had said to them that he wanted to collect some of the crystals in Kitum Cave. So he beat on the walls of the cave with a hammer and collected some rocks with crystals in them. The rocks were broken up by the driver and washed by the cook.
We tested their blood, and they were not positive for Marburg."
It seems possible that the point of contact had been the boy's hands, that the virus had entered Cardinal's bloodstream through a tiny cut. Possibly he had pricked his finger on a crystal that had been contaminated with urine from some animal or the remains of a crushed insect. But even if he had pricked his finger on a crystal, that didn't tell where the virus lived in nature; it didn't identify the virus's natural host.
"We went to look at the cave," he said. "We had to protect ourselves when we went inside. We knew that Marburg is transmitted by the aerosol route."
In 1986 – the year before Peter Cardinal died – Gene Johnson had done an experiment that showed that Marburg and Ebola can indeed travel through the air. He infected monkeys with Marburg and Ebola by letting them breathe it into their lungs, and he discovered that a very small dose of airborne Marburg or Ebola could start an explosive infection in a monkey.
Therefore, Johnson wanted the members of expedition to wear breathing apparatus inside the cave.
"I brought with me these military gas masks with filters. We needed some kind of covering to put over our heads, too, or we'd get bat shit in our hair. We bought pillowcases at a local store. They were white, with big flowers. So the first time we went into the cave, it was a bunch of Kenyans and me wearing these military gas masks and these flowered pillowcases on our heads, and the Kenyans are just cracking up."
They explored the cave and made a map of it. After this scouting trip, Gene Johnson persuaded the Army to sponsor a major expedition to Kitum Cave. Half a year after Peter Cardinal died, in the spring of 1988, Gene showed up in Nairobi with twenty shipping crates full of biohazard gear and scientific equipment. It included several military body bags, for holding human cadavers, and the members of his team had a serious discussion among themselves about how to handle their own remains if one of them died of Marburg. This time, Gene felt that he was closing in on the virus. He knew it would be hard to find even if it lived inside Kitum Cave, but he felt he was getting too close to fail in his quest. The monster lived in a cave, and he was going in there to find it.
The Kenyan government agreed to close Kitum Cave to tourists while the joint Kenya-U.S. expedition searched it for viruses. The head of the expedition was Dr. Peter Tukei of Kenya Medical Research Institute. Gene Johnson conceived the idea and gathered the equipment and found the money to pay for it. There were thirty-five team members, and most of them were Kenyans, including wildlife naturalists, scientists, doctors, and 88 laborers. They brought along a large number of guinea pigs, traveling in boxes, and seventeen monkeys in cages, including baboons, Sykes' monkeys, and African green monkeys. The monkeys and guinea pigs were sentinel animals, like canaries in a coal mine: they would be placed in cages inside and near Kitum Cave in the hope that some of them would break with Marburg virus. There are no instruments that can detect a virus. The best way to find a virus in the wild, at the present time, is to place a sentinel animal at the suspected location of the virus and hope the animal gets sick. Johnson figured that if any of his monkeys or guinea pigs crashed, he would be able to isolate the virus from the sick animals and would perhaps be able to discover how the animals had caught it.
1988 SPRING
THE KITUM CAVE expedition set up headquarters in the Mount Elgon Lodge, a decayed resort dating from the nineteen twenties, when the English had ruled East Africa. The lodge had been built for sporting people and trout fishermen. It sat on a promontory overlooking the red-dirt road that wound up the mountain to Kitum Cave. It had once been surrounded by English gardens, which had partly collapsed into clay and African weeds.
Indoors there were hardwood floors, waxed daily to perfect gleam. The lodge had turrets with round rooms and medieval doors, hand-carved from African olive wood, and the living room boasted an immense fireplace with a carved mantelpiece. The staff spoke very little English, but they were intent on maintaining English hospitality for the rare guest who might happen to show up. The Mount Elgon Lodge was a monument to the incomplete failure of the British Empire, which carried on automatically, like an uncontrollable tic, in the provincial backwaters of Africa long after it had died at the core. In the evenings, as the frost-tinged night came on, the staff built fires of Elgon olive logs in the fireplaces, and the food in the dining room was horrible, in the best English tradition. There was, however, a splendid bar. It was a quaint hideaway in a round chamber, stocked with shining rows of Tusker-beer bottles and French aperitifs and obscure African brandies. The men could sit at the bar and drink Tuskers or lean on the great mantel by the fire and tell stories after a hard day in the cave wearing a space suit. A sign on the wall by the concierge's desk mentioned the delicate matter of money. It announced that since Mount Elgon Lodge's suppliers had cut off all credit to the lodge, the lodge was unfortunately unable to extend any credit to its guests.
They moved the animals up the mountain in stages, to let them get used to the climate. When they got to the valley that leads to the cave, they cleared away some underbrush and put up blue tarpaulins. The cave itself was considered to be a Level 4 hot zone. The tarp closest to the cave covered a gray area, a place where the worlds met. The men took chemical showers under the gray-area tarp, to decon their space suits after a visit to the cave. Another tarp covered a Level 3 staging area, where the men changed in and out of their space suits. Another tarp covered a Level 4 necropsy area. Under that tarp, wearing space suits, they dissected any small animals that they had trapped, looking for signs of Marburg virus.
"We were going where no one had gone before," Johnson said to me. "We brought the Biosafety Level 4 philosophy to the jungle."
They wore orange Racal space suits inside the cave. A Racal suit is a portable, positive-pressure space suit with a battery-powered air supply. It is for use in fieldwork with extreme biohazards that are believed to be airborne. A Racal suit is also known as an orange suit because it is bright orange. It is lighter than a Chemturion, and unlike a Chemturion, it is fully portable, with a self-contained breathing apparatus. The main body of the suit (apart from helmet and the blowers) is disposable, so that you can burn it after using it once or twice.
Wearing their Racal space units, they laid out a trail that wound into Kitum Cave, marking the trail with avalanche poles so that people would not get lost. Along the trail, they placed cages holding the monkeys and guinea pigs. They surrounded the cages with electrified wire, powered by a battery, to discourage leopards from trying to eat the monkeys. They placed some of the monkeys directly underneath bat colonies in the roof of the cave, hoping that something would drop on a monkey that would cause the animal to break with Marburg.
They collected somewhere between thirty thousand and seventy thousand biting insects inside the cave – the cave is full of bugs. "We put stickum paper over cracks in the cave, to catch crawling bugs," Johnson said to me.
"We hung light traps inside the cave to collect flying insects. The light traps were battery powered. You know how to collect ticks? They come out of the ground when they smell carbon dioxide from your breath. They smell it and come up and bite your ass. So we brought these huge tanks of carbon dioxide, and we used it to attract ticks. We trapped all the rodents that went into the cave. We used Havahart traps.
Way at the back of the cave, by a pool of water, we found sand flies.
These are biting flies. We saw leopard tracks all over the place, and Cape buffalo tracks. We didn't take any food samples from large animals, nothing from leopards or buffalo. Nothing from the antelopes."
"Could Marburg live in large African cats?" I asked. "Could it be a leopard virus?"
"Maybe. We just didn't have permits to trap leopards. We did collect genet cats, and it wasn't there."
"Could it live in elephants? Did you ever try to draw blood from a wild elephant?"
We didn't."
The Kenyan naturalists trapped and netted hundreds of birds, rodents, hyaxes, and bats. In the hot necropsy zone, under the tarp, they sacrificed the animals and dissected them while wearing Racal suits, taking samples of blood and tissue, which they froze in jars of liquid nitrogen. Some local people – they were Elgon Masai – had lived inside some of the caves on Mount Elgon and had kept their cattle in the caves. The Kenyan doctors drew blood from their cattle. None of the local people or the cattle tested positive for Marburg antibodies – if they had tested positive, it would have shown that they had been exposed to Marburg.
Despite the fact that nobody showed signs of having been infected, the Elgon Masai could tell stories of how a family member, a child or a young wife, had died bleeding in someone's arms. They had seen family members crash and bleed out, but whether their illnesses were caused by Marburg or some other virus – who could tell? Perhaps the local Masa people knew the Marburg agent in their own way. If so, they had never given it a name.
None of the sentinel monkeys became sick. They remained healthy and bored, having sat in their cages in the cave for weeks. The experiment required that they be sacrificed at the end of the time so that the researchers could take tissue samples and observe their bodies for any signs of infection. At this point, the hard part of primate research began to torment Gene Johnson. He could not bring himself to euthanize the monkeys. He couldn't stand the idea of killing them and couldn't go into the cave to finish the job. He waited outside in the forest while another member of the team put on a space suit and went inside and gave the monkeys massive shots of sedative, which put them to sleep forever.
"I don't like killing animals," he said to me. "That was a major issue for me. After you've fed 'em bananas. That was terrible. It sucked." He put on his orange Racal space suit and opened up the monkeys under necropsy tent, feeling frustrated and sad, especially when all the monkeys turned out to be healthy.
The expedition was a dry hole. All the sentinel animals remained healthy, and the blood and tissue samples from the other animals, insects, birds, Masai people, and their cattle showed no sign of Marburg virus. It must have been a bitter disappointment for Gene Johnson, so disheartening that he was never able to bring himself to publish an account of the expedition and its findings. There seemed to be no point in publishing the fact that he hadn't found anything in Kitum Cave. All that he could say for sure is that Marburg lives in the shadow of Mount Elgon.
What Johnson did not know at the time, but what he sensed almost instinctively after the failure of the Kitum Cave expedition, was that the knowledge and experience he gained inside a cover in Africa, and the space suits and biohazard gear he carried back with him to the Institute, might serve him well at another time and in another place. He kept his African gear hidden away at the Institute, piled in olive-drab military trunks in storage rooms and in tractor trailers parked behind buildings and padlocked, because he did not want anyone else to touch his gear or use it or take it away from him. He wanted to be ready to load it on an airplane at a moment's notice, in case Marburg or Ebola came to the surface again in Africa. And sometimes he thought of a favorite saying, a remark by Louis Pasteur, "Chance favors the prepared mind." Pasteur developed vaccines for anthrax and rabies.
1989 SUMMER
THE ARMY HAD always had a hard time figuring out what to do with Nancy and Jerry Jaax. They were married officers at the same rank in a small corps, the veterinary Corps. What do you do with a married pair of doggy doctors who need to be promoted? What if one of them (the wife) is trained in the use of space suits? Where do you send them? The Army assigned the Jaaxes to the Institute of Chemical Defense, near Aberdeen, Maryland. They sold their Victorian house and moved, bring their birds and animals with them.
Nancy was not sorry to leave the house in Thurmont. They moved into a tract house, which was more to her liking, and there they began to raise fish in tanks, as a hobby, and Nancy went to work in an Army program to study the effects of nerve gas on rat brains. Her job was to open up the rat's head and figure out what the nerve gas has done to the brain. This was safer and more pleasant than working with Ebola, but it was a little dull. Eventually she and Jerry both received promotions to lieutenant colonel and wore silver oak leaves on their shoulders. Jaime and Jason were growing up. Jaime became a superb gymnast, short and wiry like Nancy , and Nancy and Jerry had hopes for her in the nationals, if not the Olympics. Jason grew into a tall, quiet kid. Herky, their parrot, did not change. Parrots live for many years. He went on shouting "Mom! Mom!" and whistling the march from The Bridge on The River Kwai.
Colonel Tony Johnson, Nancy's commanding officer when she had worked at USAMRIID, remembered her competence in a space suit and wanted to get her back. He felt she belonged at the Institute. He was eventually appointed head of pathology at Walter Reed Army Medical Center, and when that happened, his old job came open, the job of chief of pathology at the Institute. He urged the Army to appoint Nancy Jaax to the position, and the Army listened. They agreed that she ought to be doing hot biological work, and she got the job in the summer of 1989. At the same time, the Army appointed Jerry Jaax head of the veterinary division at the Institute. So the Jaax became important and rather powerful figures. Nancy went back to biological work in space suits.
Jerry still didn't like it, but he had learned to live with it.
With these promotions, the Jaax sold their house in Aberdeen and moved back to Thurmont, in August 1989. This time, Nancy told Jerry it was not going to be a Victorian. They bought a contemporary Cape house with dormer windows, with a lot of land around it, meadow and forest, where the dogs could run and the children could play. Their house stood on the lower slope of Catoctin Mountain, overlooking the town, above a sea of apple orchards. From their kitchen window, they could look into the distance over rolling farmland where armies had marched during the Civil War. Central Maryland stretched away to the horizon in folds and hollows, in bands of trees and rumpled field, studded by silos that marked the presence of family farms. High over the beautiful countryside, passenger jets crisscrossed the sky, leaving white contrails behind them.
The surface of the tongue turns brilliant red and then sloughs off, and is swallowed or spat out. It is said to be extraordinarily painful to lose the surface of one's tongue. The tongue's skin may be torn off during rushes of the black vomit. The back of the throat and the lining of the windpipe may also slough off, and the dead tissue slides down the windpipe into the lungs or is coughed up with sputum. Your heart bleeds into itself; the heart muscle softens and has hemorrhages into its chambers, and blood squeezes out of the heart muscle as the heart beats, and it floods the chest cavity. The brain becomes clogged with dead blood cells, a condition known as sludging of the brain. Ebola attacks the lining of the eyeball, and the eyeballs may fill up with blood: you may go blind.
Droplets of blood stand out on the eyelids: you may weep blood. The blood runs from your eyes down your cheeks and refuses to coagulate. You may have a hemispherical stroke, in which one whole side of the body is paralyzed, which is invariably fatal in a case of Ebola. Even while the body's internal organs are becoming plugged with coagulated blood, the blood that streams out of the body cannot clot; it resembles when being squeezed out of curds. The blood has been stripped of its clotting factors. If you put the runny Ebola blood in a test tube and look at it, you see that the blood is destroyed. Its red cells are broken and dead.
The blood looks as if it has been buzzed in an electric blender.
Ebola kills a great deal of tissue while the host is still alive.
It triggers a creeping, spotty necrosis that spreads through all the internal organs. The liver bulges up and turns yellow, begins to liquefy, and then it cracks apart. The cracks run across the liver and deep inside it, and the liver completely dies and goes putrid. The kidneys become jammed with blood clots and dead cells, and cease functioning. As the kidneys fail, the blood becomes toxic with urine. The spleen turns into a single huge, hard blood clot the size of a baseball. The intestines may fill up completely with blood. The lining of the gut dies and sloughs off into the bowels and is defecated along with large amounts of blood. In men, the testicles bloat up and turn black-and-blue, the semen goes hot with Ebola, and the nipples may bleed. In women, the labia turn blue, livid, and protrusive, and there may be massive vaginal bleeding. The virus is a catastrophe for a pregnant woman: the child is aborted spontaneously and is usually infected with Ebola virus, born with red eyes and a bloody nose.
Ebola destroys the brain more thoroughly than does Marburg, and Ebola victims often go into epileptic convulsions during the final stage.
The convulsions are generalized grand mal seizures – the whole body twitches and shakes, the arms and legs thrash around, and the eyes, sometimes bloody, roll up into the head. The tremors and convulsions of the patient may smear or splatter blood around. Possibly this epileptic splashing of blood is one of Ebola's strategies for success – it makes the victim go into a flurry of seizures as he dies, spreading blood all over the place, thus giving the virus a chance to jump to a new host – a kind of transmission through smearing.
Ebola (and Marburg) multiplies so rapidly and powerfully that the body's infected cells become crystal-like blocks of packed virus particles. These crystals are broods of virus getting ready to hatch from the cell. They are known as bricks. The bricks, or crystals, first appear near the center of the cell and then migrate toward the surface.
As a crystal reaches a cell wall, it disintegrates into hundreds of individual virus particles, and the bloodlings push through the cell wall like hair and float away in the bloodstream of the host. The hatched Ebola particles cling to cells everywhere in the body, and get inside them, and continue to multiply. It keeps on multiplying until areas of tissue all through the body are filled with crystalloids, which hatch, and more Ebola particles drift into the bloodstream, and the amplification continues inexorably until a droplet of host's blood can contain a hundred million individual virus particles.
After death, the cadaver suddenly deteriorates: the internal organs, having been dead or partially dead for days, have already begun to dissolve, and a sort of shock-related meltdown occurs. The corpse's connective tissue, skin, and organs, already peppered with dead spots, heated by fever, and damaged by shock, begin to liquefy, and the fluids that leak from the cadaver are saturated with Ebola-virus particles.
WHEN IT WAS all over, the floor, chair, and walls in Sister M.E's hospital room were stained with blood. Someone who saw the room told me that after they took her body away for burial (wrapped in many sheets), no one at the hospital could bear to go into the room to clean it up. The nurses and doctors didn't want to touch the blood on the walls and were frankly fearful of breathing the air in the room, too. So the room was closed and locked, and remained that way for days. The appearance of the nun's hospital room after her death may have raised in some minds one or two question about the nature of the Supreme Being, or, for persons not inclined to theology, the blood on the walls may have served as a reminder of the nature of Nature.
No one knew what had killed the nun, but clearly it was a replicating agent, and the signs and symptoms of the disease were not easy to consider with a calm mind. What also did not lead to calm thoughts were rumors coming out of the jungle to the effect that the agent was wiping out whole villages upriver on the Congo. These rumors were not true. The virus was hitting families selectively, but no one understood this because the flow of news coming from upriver was being choked off.
Doctors at the hospital in Kinshasa examined the nun's case and began to suspect that she might have died of Marburg or a Marburg -like agent.
Then Sister E.R., the nun who had traveled with Sister M.E. during the drive to Bumba and the plane flight to Kinshasa, broke with l'epidémie. They put her in a private room at the hospital, where she began to die with the same signs and symptoms that had preceded Sister M.E.'s death.
There was a young nurse at the Ngaliema Hospital named Mayinga N. (Her first name was Mayinga and her last name is given as N.) Nurse Mayinga had been caring for Sister M.E. when the nun had died in the bloodstained room. She may have been splattered with the nun's blood or with black vomit. At any rate, Nurse Mayinga developed a headache and fatigue. She knew she was becoming sick, but she did not want to admit to herself what it was. She came from a poor but ambitious family, and she had received a scholarship to go to college in Europe. What worried her was the possibility that if she became ill, she would not be allowed to travel abroad. When the headache came upon her, she left her job at the hospital and disappeared. She dropped out of sight for two days. During that time, she went into the city, hoping to get her travel permits arranged before she became visibly sick. On the first day of her disappearance – the date was October 12, 1976 – she spent a day waiting in lines at the offices of the Zairean foreign ministry, trying to get her papers straight.
The next day, October 13, she felt worse, but instead of reporting to work, again she went into the city. This time, she took a taxi to the largest hospital in Kinshasa, the Mama Yemo Hospital. By now, as her headache became blinding and her stomach pain increased, she must have been terribly frightened. Why didn't she go to the Ngaliema Hospital to seek treatment where she worked and where the doctors would have taken care of her? It must have been a case of psychological denial. She did not want to admit, even to herself, that she had been infected. Perhaps she had a touch of malaria, she hoped. So she went to Mama Yemo Hospital, the hospital of last resort for the city's poor, and spent hours waiting in a casualty ward jammed with ragged people and children.
I can see her in my mind's eye – Nurse Mayinga, the source of the virus in the United States Army's freezers. She was a pleasant, quiet, beautiful young African woman, about twenty years old, in the prime of her life, with a future and dreams, hoping somehow that what was happening to her could not be happening. They say that her parents loved her dearly, that she was the apple of their eye. Now she is sitting in the casualty ward at Mama Yemo among the cases of malaria, among the large-bellied children in rags, and no one is paying any attention to her because all she has is a headache and red eyes. Perhaps the fact that she is crying has made her eyes red. A doctor gives her a shot for malaria and tells her that she should be in quarantine for her illness. But there is no room in the quarantine ward at Mama Yemo Hospital; so she leaves the hospital and hails another taxi. She tells the driver to take her to another hospital, to University Hospital, where perhaps the doctors can treat her. But when she arrives at University Hospital, the doctors can't seem to find anything wrong with her, except for possibly some sign of malaria. Her headache is getting worse. She is sitting in the waiting room of this hospital, and as I try to imagine her there, I am almost certain she is crying. Finally she does the only thing left for her to do. She returns to Ngaliema Hospital and asks to be admitted as a patient. They put her in a private room, and there she falls into lethargy, and her face freezes into a mask.
News of the virus and what it did to people had been trickling out of the forest, and now a rumor that a sick nurse had wandered around Kinshasa for two days, having face-to-face contact with many people in crowded rooms and public places, caused a panic in the city. The news spread first along the mission grapevine and through government employees and among the diplomats at cocktail parties, and finally the rumors began to reach Europe. When the story reached the offices of the World Health Organization in Geneva, the place went into a full-scale alert. People who were there at the time said that you could feel fear in the hallways, and the director looked like a visibly shaken man. Nurse Mayinga seemed to be a vector for an explosive claim of lethal transmission in a crowded third-world city with a population of two million people. Officials at the WHO began to fear that Nurse Mayinga would become the vector for a world-wide plague. European governments contemplated blocking flights from Kinshasa. The fact that one infected person had wandered around the city for two days when she should have been isolated in a hospital room began to look like a species threatening event.
President Mobutu Sese Seko, the maximum leader of Zaire, sent his army into action. He stationed soldiers around Ngaliema Hospital with orders to let no one enter or leave except doctors. Much of the medical staff was not under quarantine inside the hospital, but the soldiers made sure that the quarantine was enforced. President Mobutu also ordered army units to seal off Bumba Zone with roadblocks and to shoot anyone trying to come out. Bumba's main link with the outside world was the Congo River.
Captains of riverboats had heard about the virus by this time, and they refused to stop their boats anywhere along the length of the river in Bumba, even though people beseeched them from the banks. Then all radio contact with Bumba was lost. No one knew what was happening upriver, who was dying, what the virus was doing. Bumba had dropped off the face of the earth into the silent heart of darkness.
AS THE FIRST nun at Ngaliema Hospital, Sister M.E., lay dying, her doctors had decided to give her a so-called agonal biopsy. This is a rapid sampling of tissue, done close to the moment of death instead of a full autopsy. She was a member of a religious order that prohibited autopsies, but the doctors very much wanted to know what was replicating inside her.
As the terminal shock and convulsions came over her, they inserted a needle into her upper abdomen and sucked out a quantity of liver. Her liver had begun to liquefy, and the needle was large. A fair amount of the nun's liver traveled up the needle and filled a biopsy syringe.
Possibly it was during this agonal biopsy that her blood squirted on the walls. The doctors also took some samples of blood from her arm and put it in glass tubes. The nun's blood was precious beyond measure, since it contained the unknown hot agent.
The blood was flown to a national laboratory in Belgium and to the England natural laboratory, the Microbiological Research Establishment at Porton Down, in Wiltshire. Scientists at both labs began racing to identify the agent. Meanwhile, at the Centers for Disease Control in Atlanta, Georgia – the C.D.C. – scientists were feeling left out, and were still scrambling to get their hands on a little bit of the nun's blood, making telephone calls to Africa and Europe, pleading for the samples.
There is a branch of the C.D.C. that deals with unknown emerging viruses. It's called the Special Pathogens Branch. In 1976, at the time of the Zaire outbreak, the branch was being run by a doctor named Karl M. Johnson, a virus hunter whose home terrain had been the rain forests of Central and South America. (He is not related to Gene Johnson, the civilian virus hunter, or to Lieutenant Colonel Tony Johnson, the pathologist.) Karl Johnson and his C.D.C. colleagues had heard almost nothing about the occurrences upriver in Zaire – all they knew was that people in Zaire were dying of a "fever" that had "generalized symptoms" – no details had come in from the bush or from the hospital where the nun had just died. Yet it sounded like a bad one. Johnson telephoned a friend of his at the English lab, in Porton Down, and reportedly said to him, "If you've got any little dregs to spare of that nun's blood, we'd like to have a look at it." The Englishman agreed to send it to him, and what he received was literally dregs.
The nun's blood arrived at C.D.C. in glass tubes in a box lined with dry ice. The tubes had cracked and broken during shipment, and raw, rotten blood had run around inside the box. A C.D.C. virologist named Patricia Webb – who was then married to Johnson – opened the box. She found that the package was sticky with blood. The blood looked like tar. It was black and gooey, like Turkish coffee. She put on rubber gloves, but other than that, she did not take any special precautions in handling the blood. Using some cotton balls, she managed to dab up some of the black stuff, and then by squeezing the cotton between her fingertips, she collected a few droplets of it, just enough to begin testing it for viruses.
Patrica Webb put some of the black blood droplets into flasks of monkey cells, and pretty soon the cells got sick and began to die – they burst. The unknown agent could infect monkey cells and pop them.
Another C.D.C. doctor who worked on the unknown virus was Frederick A. Murphy, a virologist who had helped to identify Marburg virus. He was and is one of the world's leading electron-microscope photographers of viruses. (His photographs of viruses have been exhibited in art museums.) Murphy wanted to take a close look at those dying cells to see if he could photograph a virus in them. On October 13 – the same day Nurse Mayinga was sitting in the waiting rooms of hospitals in Kinshasa – he placed a droplet of fluid from the cells on a small screen and let it dry, and he put it in his electron microscope to see what he could see.
He couldn't believe his eyes. The sample was jammed with virus particles. The dried fluid was shot through with something that looked like string. His breath stopped in his throat. He thought, Marburg. He believed he was looking at Marburg virus.
Murphy stood up abruptly, feeling strange. The lab where he had prepared these samples – that lab was hot. The lab was as hot as hell. He went out of the microscope room, closing the door behind him, and hurried down a hallway to the laboratory where he had worked with the material.
He got a bottle of Clorox bleach and scrubbed the room from top to bottom, washing countertops and sinks, everything, with bleach. He really scoured the place. After he had finished, he found Patricia Webb and told her what he had seen in his microscope. She telephoned her husband and said to him, "Karl, you'd better come quick to the lab. Fred has looked at a specimen, and he's got worms."
Staring at the worms, they tried to classify the shapes. They saw snakes, pigtails, branchy, forked things that looked like the letter Y, and they noticed squiggles like a small g, and bends like the letter U, and loopy 6s. They also noticed a classic shape, which they began calling the shepherd's crook. Other Ebola experts have taken to calling this loop the eyebolt, after a bolt of the same name that can be found in a hardware store. It could also be described as a Cheerio with a long tail.
The next day, Patrica Webb ran some tests on the virus and found that it did not react to any of the tests for Marburg or any other known virus. Therefore, it was an unknown agent, a new virus. She and her colleagues had isolated the strain and shown that it was something new.
They had earned the right to name the organism. Karl Johnson named it Ebola.
Karl Johnson has since left the C.D.C., and he now spends a great deal of his time fly-fishing for trout in Montana. He does consulting work on various matters, including the design of pressurized hot zones. I learned that he could be reached at a fax number in Big Sky, Montana, so I sent him a fax. In it, I said that I was fascinated by Ebola virus. My fax was received, but there was no reply. So I waited a day and then sent him another fax. It fell away into silence. The man must have been too busy fishing to bother to answer. After I had given up hope, my fax machine suddenly emitted this reply:
Mr. Preston:
Unless you include the feeling generated by gazing into the eyes of a waving confrontational cobra, "fascination" is not what I feel about Ebola. How about shit scared?"
Two days after he and his colleagues isolated Ebola virus for the first time, Karl Johnson headed for Africa in the company of two other C.D.C. doctors, along with seventeen boxes of gear, to try to organize an effort to stop the 73 virus in Zaire and Sudan (the outbreak in Sudan was still going on). They flew first to Geneva, to make contact with the World Health Organization, where they found that the WHO knew very little about the outbreaks. So the C.D.C. doctors organized their equipment and packed more boxes, getting ready to go to the Geneva airport, from where they would fly to Africa. But then, at the last possible moment, one of C.D.C. doctors panicked. It is said he was the doctor assigned to go to Sudan, and it is said he was afraid to proceed any farther. It was not an unusual situation. As Karl Johnson explained to me, "I've seen young physicians run from these hemorrhagic viruses, literally. They're unable to work in the middle of an outbreak. They refuse to get off the plane."
Johnson, one of the discoverers of Ebola virus, preferred to talk about these events while fly-fishing. ("We've got to keep our priorities straight," he explained to me.) So I flew to Montana and spent a couple of days with him fishing for brown trout on the Bighorn River. It was October, the weather had turned clear and warm, and the cottonwood trees along the banks were yellow and rattled in a south wind. Standing waist-deep in a mutable slick of the river, wearing sunglasses, with a cigarette hanging from the corner of his mouth and a fly rod in his hand, Johnson ripped his line off the water and laid a cast upstream. He was a lean, bearded man, with a soft voice that one had to listen for in the wind. He is a great figure in the history of virus hunting, having discovered and named some of the most dangerous life forms on the planet.
"I'm so glad nature is not benign," he remarked. He studied the water, took a step downstream, and placed another cast. "But on a day like today, we can pretend nature is benign. All monsters and beasts have their benign moments."
"What happened in Zaire?" I asked.
"When we got to Kinshasa, the place was an absolute mad house," he said. "There was no news coming out of Bumba, no radio contact. We knew it was bad in there, and we knew we were dealing with something new. We didn't know if the virus could be spread by droplets in the air, something like influenza. If Ebola had spread easily through the air, the world would be a very different place today."
"How so?"
"There would be a lot fewer of us. It would have been exceedingly difficult to confirm that virus if it had any major respiratory component.
I did figure that if Ebola was the Andromeda strain – incredibly lethal and spread by droplet infection – there wasn't going to be any safe place in the world anyway. It was better to be working at the epicenter than to get the infection at the London opera."
"Are you worried about a species-threatening event?"
He stared at me, "What the hell do you mean by that?"
"I mean a virus that wipes us out."
"Well, I think it could happen. Certainly it hasn't happened yet. I'm not worried. More likely it would be a virus that reduces us by ninety percent."
"Nine out of ten human killed? And you're not bothered."
A look of mysterious amusement crossed his face. "A virus can be useful to a species by thinning it out," he said.
A scream cut the air. It sound nonhuman. He took his eyes off the water and looked around. "Hear that pheasant? That's what I like about the Bighorn River," he said.
"Do you find viruses beautiful?"
"Oh, yeah," he said softly. "Isn't true that if you stare into the eyes of a cobra, the fear has another side to it? The fear is lessened as you begin to see the essence of the beauty. Looking at Ebola under an electron microscope is looking at a gorgeously wrought ice castle. The thing is cold. So totally pure."
Karl Johnson became the chief of an international WHO team that gathered in Kinshasa.
THE OTHER C.D.C. doctor, Joel Breman, who had flown with Johnson to Zaire, became a member of a field exploration team that boarded an aircraft bound for the interior to see what was going on in Bumba. The airplane was a C-130 Buffalo troop-transport, an American-made military aircraft that belonged to the Zaire Air Force. It happened to be President Mobutu's private plane, equipped with leopard-skin seats, folding beds, and a wet bar, a sort of flying presidential palace that ordinarily took the president and his family on vacations to Switzerland, but now it carried the WHO team into the hot zone, following the Congo River north by east.
They sat on the leopard-skin seats and stared out the windows at endless tracts of rain forest and brown river, a featureless blanket broken by the occasional gleam of an oxbow lake or a cluster of round huts strung like beads on a barely visible road or footpath. As he leaned against the window and watched the terrain unfold into the heart of Africa, Breman became terrified of coming to earth. It was safe in the air, high above the immeasurable forest, but down there ... It began to dawn on him that he was going to Bumba to die. He had recently been assigned to Michigan as a state epidemiologist, and suddenly he had been called to Africa. He had left his wife back home in Michigan with their two children, and he began to suspect that he would never see them again. He had brought an overnight bag with a toothbrush, and he had managed to pack a few paper surgical masks and some gowns and rubber gloves into the bag. He did not have proper equipment for handling a hot agent. The Buffalo descended, and the town of Bumba appeared, a rotting tropical port spread out along the Congo River.
The Buffalo landed at an airstrip outside the town. The plane's Zaire crew was terrified, afraid to breathe the air, and they left the propellers idling while they showed the doctors down the gangway and heaved their bags out after them. The doctors found themselves standing in the backwash of the Buffalo as it accelerated to take off.
In the town, they met with the governor of Bumba Zone. He was a local politician, quite distraught. He had found himself in deep waters, in over his head. "We are in a bad way," he told the doctors. "We have not been able to get salt or sugar." His voice trembled on the edge of weeping as he added, "We have not even been able to get beer."
A Belgian doctor on the team knew how to handle this situation.
With a dramatic flourish, he placed a black airline pilot's bag on the table. Then he turned the bag upside down, and wads of currency slapped out, making an impressive heap. "Governor, perhaps this will make things a little better." he said.
"What are you doing?" Breman said to the Belgian.
The Belgian shrugged. "Look, this is the way things are done here."
The governor scooped up the money and pledged his full cooperation together with all the extensive resources of government at his disposal – and he loaned them two Land Rovers.
They pushed north toward the Ebola River.
It was the rainy season, and the "road" was a string of mud holes cut by running streams. Engines howling, wheels spinning, they proceeded through the forest at the pace of a wall, in continual rain and oppressive heat. Occasionally they came to villages, and at each village they encountered a roadblock of fallen trees. Having had centuries of experience with the smallpox virus, the village elders had instituted their own methods for controlling the virus, according to their received wisdom, which was to cut their villages off from the world, to protect their people from a raging plague. It was reverse quarantine, an ancient practice in Africa, where a village bars itself from strangers during a time of disease, and drives away outside who appear.
"Who are you? What are you doing?" they shouted to the Land Rovers from behind a barrier of trees.
"We are doctors! We are coming to help!"
Eventually the people would clear away the trees, and the team would proceed deeper into the forest. In a long and desperate day of travel, they penetrated fifty miles away from the Congo River, and finally, toward evening, they came to a row of round, hatched African houses. Beyond the houses stood a white church in the middle of the forest. Around the church, there were two soccer fields, and in the middle of one field they noticed a heap of burned mattresses. Two hundred yards farther on, they came to the Yambuku Mission Hospital, a complex of low, whitewashed buildings made of concrete, with corrugated tin roofs.
The place was as silent as a tomb and appeared to be deserted.
The beds were iron or wooden frames without mattresses – the blood-soaked mattresses had been burned in the soccer field – and the floors were clean, spotless, rinsed. The team discovered three surviving nuns and one priest, along with a few devoted African nurses. They had cleaned up the mess after the virus had wiped out everyone else, and now they were busy fogging the rooms with insecticide, in the hope that it might somehow disperse the virus. One room in the hospital had not been cleaned up. No one, not even the nuns, had the courage to enter the obstetric ward. When Joel Breman and the team went in, they found basins of foul water standing among discarded, bloodstained syringes. The room had been abandoned in the middle of childbirths, where dying mothers had aborted fetuses infected with Ebola. The team had discovered the red chamber of virus queen at the end of the earth, where the life form had amplified through mothers and their unborn children.
The rains continued all day and night. Around the hospital and the church stood the beautiful ferocious trees, a complex of camphor's and teaks. Their crowns entwined and crisscrossed and whispered with rain, and bowed and shifted as troops of monkeys passed through them like currents of wind, leaping from crown to crown, crying their untranslatable cries. The next day, the doctors set out deeper into the forest in their Land Rovers, and they made contact with infected villages, where they found people dying in huts. Some of the victims had been put into isolation huts on the edge of the village-an old African technique for dealing with smallpox. Some of the huts where people had died had been burned down. Already the virus seemed to be petering out, and most of the people who were going to die were already dead, the virus having echoed so swiftly through Bumba. A wave of emotion rolled over Joel Breman as he realized, with the clarity of a doctor who suddenly sees into the heart of things, that the victims had received the infection from the hospital.
The virus had taken root with the nuns and had done its work among those who had sought help from them. In one village, he examined a man dying of 78 Ebola. The man sat in a chair, holding his stomach and leaning forward with pain, and blood streamed around his teeth.
They tried to reach Kinshasa by radio, to tell Karl Johnson and the others that the epidemic had already peaked. A week later, they were still trying to make radio contact, but they could not get through. They traveled back to the town of Bumba and waited by the river. One day an airplane droned overhead. It circled the town once and touched down, and they ran for it.
AT THE NGALIEMA HOSPITAL in Kinshasa, Nurse Mayinga had been put into a private room, which was accessible through a kind of empty room, a gray zone, where the nurses and staff were supposed to put on bio-protective gear before they entered. Mayinga was cared by a South African doctor named Margaretha Isaacson, who at first wore a military gas mask, but it became increasingly uncomfortable in the tropical heat. She thought to herself, I can't bear it. I'll be surprised if I come out of this alive anyway. That made her think about her own children. She thought, My children are grown up, they are no great responsibility. And she removed her mask and treated the dying girl face-to-face.
Dr. Isaacson did everything she could to save Mayinga, but she was as helpless before the agent as medieval doctors had been in the face of the black plague. ("This was not like AIDS," she would later recall. "AIDS is a child's play compared with this.") She gave Nurse Mayinga ice cubes to suck on, which helped to ease the pain in her throat, and she gave her Valium to try to stave off her apprehension of what lay ahead.
"I know I am dying," Mayinga said to her.
"That's nonsense. You are not going to die." Dr. Isaacson replied.
When Mayinga's bleeding began, it came from her mouth and nose.
It never came in a rush, but the blood dripped and ran and would not stop and would not clot. It was a hemorrhagic nose bleed, the kind that does not stop until the heart stops beating. Eventually Dr. Isaacson gave her three transfusions of whole blood to replace what she lost in nosebleeds.
Mayinga remained conscious and despondent until the end. In the final stage, her heart developed a galloping beat. Ebola had entered her heart.
Mayinga could feel her heart going blubbery inside her chest, and it frightened her unspeakably. That night, she died of a heart attack.
Her room was contaminated with blood, and there was also the question of the two nuns' rooms, both of which were still locked and bloodstained. R. Isaacson said to the staff, "I won't be of much use to you now," and she got a bucket and mop and washed the rooms.
Medical teams fanned out into Kinshasa and managed to locate thirty-seven people who had face-to-face contact with Mayinga during the time when she had wandered around the city. They set up two biocontainment pavilions at the hospital and shut the people up for a couple of weeks. They wrapped like cadavers of the nuns an Nurse Mayinga in sheets soaked in chemicals, then double-bagged the mummies in plastic and put each one in an airtight coffin which a screw-down lid, and held the funeral services at the hospital, under the watch of doctors.
Karl Johnson, having heard nothing from the team of doctors upriver in Bumba, wondered if they were dead, and assumed that the virus was about to go on a burn through the city. He organized a floating hospital ship and had it moored in the Congo River. It was an isolation ship for doctors. The city would be the hot zone, and the floating ship would be the gray area, the place of refuge for the doctors.
Approximately a thousand Americans were living in Zaire at the time. In the United States, the Amy's Eighty-second Airborne Division went on alert and prepared to evacuate the Americans by air as soon as the first Ebola cases started popping up in the city. But to the strange and wonderful relief of Zaire and the world, the virus never went on a burn through the city. It subsides on the headwaters of the Ebola River and went back to its hiding place in the forest. The Ebola agent seemed not to be contagious in face-toface contacts. It did not seem to be able to travel through the air. No one caught the virus from Nurse Mayinga, even though she had been in close contact with at least thirty-seven people. She had shared a bottle soda pop with someone, and not even that person became ill. The crisis passed.
CARDINAL
1987 SEPTEMBER AS WITH EBOLA, the secret hiding place of the Marburg agent was unknown.
After erupting in Charles Monet and Dr. Shem Musoke, Marburg dropped out of sight, and no one could say where it had gone. It seemed to vanish off the face of the earth, but viruses never go away, they only hide, andMarburg continued to cycle in some reservoir of animals or insects in Africa.
On the second of day of September 1987, around suppertime, Eugene Johnson, the civilian biohazard expert attached to USAMRIID, stood in a passenger-arrival area outside the customs gates at Dulles International Airport, near Washington. He was waiting for a KLM flight from Amsterdam, which carried a passenger who had come from Kenya. A man with a duffle bag passed through customs, and he and Johnson nodded to each other.
("I'm going to leave this person's name out of it. Let's just say he was someone I knew, someone I trust." Johnson explained to me). The man laid down the duffle bag at Johnson's feet, unzipped it, and pulled out a wad of bath towels wrapped around something. Pulling off the towels, he revealed an unmarked cardboard box wound with tape. He handed the box to Johnson. They had little to say to each other. Johnson carried the box out of the terminal building, put it in the trunk of his car, and drove to the Institute. The box held blood serum from a ten-year-old Danish boy who will be called Peter Cardinal. He had died a day or so earlier at Nairobi Hospital with a combination of extreme symptoms that suggested an unidentified Level 4 virus.
As he drove to the Institute, Johnson wondered just what he was going to do with the box. He was inclined to sterilize its contents in an oven and then incinerate it. Just cook it and burn it, and forget it.
Most of the samples that came into the Institute – and samples of blood and tissue arrived constantly from all parts of the world – contained nothing unusual, no interesting viruses. In other words, most of the samples were false alarms. Johnson wasn't sure he wanted to take the time to analyze this boy's blood serum, if, in all probability, nothing would be found in it. By the time he pulled into the gates of Fork Detrick, he had decided to go ahead. He knew the work would keep him up most of the night, but it had to be done immediately, before the blood serum deteriorated.
Johnson put on a surgical scrub suit and rubber gloves, and carried the box into the Level 3 staging area of the Ebola suite, where he opened the box, revealing a mass of foam peanuts. Out of the peanuts he fished a metal cylinder sealed with tape and marked with a biohazard symbol. Along the wall of the staging area was a row of stainless-steel cabinets with rubber gloves protruding into them. They were Biosafety Level 4 cabinets. They could be sealed off from the outside world while you handled a hot agent inside them with the rubber gloves. These cabinets were similar in design to the safety cabinets that are used to handling nuclear-bomb parts. Here the cabinets were designed to keep human beings from coming into direct contact with Nature. Johnson unscrewed some wing nuts and opened a door in the cabinets, and placed the metal cylinder inside. He closed and tightened the door.
Next, he put his hands into the gloves, picked up the cylinder and, looking through a window to see what he was doing, peeled the tape off the cylinder. The tape stuck to his rubber gloves, and he couldn't get it off. Damn! he swore to himself. It was now eight o'clock at night, and he would never get home. Finally he got the cylinder open.
Inside it was a wad of paper towel soaked in bleach. He pulled apart the wad and found a Ziploc bag. It contained a couple of plastic tubes with screw tops. He unscrewed them and shook out two very small plastic vials containing golden liquid: Peter Cardinal's blood serum.
The boy's mother and father worked for a Danish relief organization in Kenya, and lived in a house in the town of Kisumu, on Lake Victoria. Peter had been a student at a boarding school in Denmark. That August, a few weeks before he died, he had gone to Africa to visit his parents and his older sister. She was a student at a private school in Nairobi. She and Peter were very close, and while Peter was visiting his family in Kenya, the two young people spent most of their time together – brother and sister, best friends.
The Cardinal family went on vacation after Peter's arrival, and traveled by car through Kenya – his mother and father wanted to show him the beauty and sweetness of Africa. They were visiting Mombasa, staying in a hotel by the sea, when Peter developed red eyes. His parents took him to the hospital, where the doctors examined him an concluded that he had come down with malaria. His mother did not believe it was malaria. She began to perceive that her son was dying, and she became frantic. She insisted that he be taken to Nairobi for treatment. The Flying Doctors, an air-ambulance service, picked him up, and he was rushed to Nairobi Hospital, where he came under care of Dr. David Silverstein, who had also taken care of Dr. Musoke after Charles Monet had spewed the black vomit into Musoke's eyes.
"PETER CARDINAL WAS a blond-haired, blue-eyed guy, a tall, thin guy, a fit-looking ten-year-old," Dr. Silverstein recalled as we drank coffee and tea at a table in the shopping mall near his house outside Washington. A small girl sitting burst into wails, and her mother hushed her. Crowds of shoppers passed by our table. I kept my eyes on Dr. Silverstein's face – steel-rimmed glasses, mustache, eyes that gazed into space – as he recalled the unusual death he had seen, which he spoke of a matter-of-fact way. "When Peter came to me, he was febrile, but he was very with it, very alert and communicative. We gave him an X-ray. His lungs were fluffy."
A kind of watery mucus had begun to collect in the boy's lungs, which caused him difficulty in breathing. "It was a typical ARDS picture – acute respiratory distress syndrome – like early pneumonia," Dr. Silverstein said.
"Shortly afterward, he started turning bluish on it. He had blue in his fingertips. Also, he had little red spots. I had everybody glove up before they handled him. We suspected he had Marburg, but we didn't have the paranoia we had with Dr. Musoke. We just took precautions. In twenty-four hours, he was on a respirator. We noted that he bled easily from puncture sites, and he had deranged liver functions. The small red spots became large, spontaneous bruises. He turned black-and-blue. Then his pupils dilated up on us. That was a sign of brain death. He was bleeding around the brain."
He swelled up, and his filled with pockets of blood. In some places, the skin almost separated from the underlying tissue. This happened during the last phase, while he was on a respirator. It is called third spacing. If you bleed into the first space, you bleed into your lungs. If you bleed into the second space, you bleed into your stomach and intestines. If you bleed into the third space, you bleed into the space between the skin and the flesh. The skin puffs up and separates from the flesh like a bag. Peter Cardinal had bled out under his skin.
THE MORE ONE contemplates the hot viruses, the less they look like parasites and the more they begin to look like predators. It is a characteristic of a predator to become invisible to its prey during the quiet and sometimes lengthy stalk that precedes an explosive attack. The savanna grass ripples on the plains, and the only sound in the air is the sound of African doves calling from acacia trees, a pulse that goes on through the heat of the day and never slows and never ends. In the distance, in the flickering heat, in the immense distance, a herd of zebras gaze. Suddenly from the grass comes a streak of movement, and a lion is among them and hangs on a zebra's throat. The zebra gives out a barking cry, choked off, and the two interlocked beings, the predator and the prey, spin around in a dance, until you lose sight of the action in a billow of dust, and the next day the bones have a surface of flies. Some of the predators that feed on humans have lived on the earth for a long time, far longer than the human race, and their origins go back, it seems, almost to the formation of the planet. When a human being is fed upon and consumed by one of them, especially in Africa, the event is telescoped against horizons of space and time, and takes on a feeling of immense antiquity.
Peter Cardinal's parents and sister were stunned as they watched him being slowing torn apart by an invisible predator. They could not comprehend his suffering or reach him to give him comfort. As the blood poured into his third space, his eyes remained open and dilated, staring, bloody, deep, dark, and bottomless. They didn't know if he could see them, and they couldn't tell what he saw or thought or felt behind the open eyes. The machines hooked up to his scalp were showing flatlines in his brain. There was little electrical activity in his brain, but now and then the flatlines gave a spooky twitch, as if something continued to struggle inside the boy, some destroyed fragment of his soul.
They had to make a decision about whether to turn off the respirator. Dr. Silverstein said to them, "We're much better off not letting him survive, because of brain death."
"If they had only brought him in sooner from Mombasa," the mother said.
"I'm sorry, but that would not have helped. There was nothing that anyone could have done," Silverstein replied to her. "He was doomed from the beginning."
WORKING WITH HIS hands in the rubber gloves protruding into the cabinets, Gene Johnson took a little bit of the boy's blood serum and dropped it into flasks that contained living cells from a monkey. If anything lived in Peter Cardinal's blood, it might begin to replicate in the monkey cells. Then Johnson went home to get some sleep. The procedure had taken him until three o'clock in the morning to finish.
In the following days, Johnson watched the flasks to see if there were any changes in the monkey cells. He saw that they were bursting and dying. They were infected with something. The Cardinal strain was definitely a hot agent – it killed the cells in vast numbers, and it killed them fast.
Now for the next stage of the virus isolation. He drew off a little bit of fluid from the flasks and injected it into three rhesus monkeys, to infect them with the Cardinal agent. Two of the monkeys died and the third animal went into borderline shock, but somehow pulled through and survived. So the Cardinal agent was viciously hot, a fast replicator, and it could kill monkeys. "I knew god-damned well we had Marburg," Johnson would later say to me.
He took some of the Cardinal strain and injected it into guinea pigs to see if it would infect them. It killed them like flies. Not only that, the testicles of the males swelled up to the size of golf balls and turned purple. The Cardinal strain was a sophisticated organism that knew what they wanted. It could multiply in many different kinds of meat. It was an invasive life form, devastating and promiscuous. It showed a kind of obscenity you see only in nature, an obscenity so extreme that it dissolves imperceptibly into beauty. It made a living somewhere in Africa. What made it particularly interesting was that it multiplied easily in various species, in monkeys, humans, guinea pigs. It was extremely lethal in these species, which meant that its original host was probably not monkeys, humans or guinea pigs but some other animal or insect that it did not kill. A virus does not generally kill its natural host. The Marburg virus was a traveler: it could jump species; it could break through the lines that separate one species from another, and when it jumped into another species, it could devastate the species. It did not know boundaries. It did not know what humans are; or perhaps you could say that it knew only too well what humans are: it knew that humans are meat.
As soon as he isolated the Cardinal strain and confirmed that it was Marburg, Johnson turned his attention to the question of where and how Peter Cardinal might have become infected. Where had that kid been? What had he been doing to get himself infected? Exactly where had he traveled?
These questions haunted Johnson. He had been trying to find the secret reservoirs of the thread viruses for years.
He telephoned a friend and colleague in Kenya named Dr. Peter Turkei, who was a scientist at the Kenya Medical Research Institute in Nairobi. "We know this is Marburg," Gene said to him. "Can you get a history of the kid? Find out where he was and what he did?"
Dr. Tukei said he would locate the parents and interview them.
A week later, Gene's telephone rang. It was Dr. Tukei on the line.
"You know where that kid was?" he said. "He was in Kitum Cave on Mount Elgon."
Gene felt a prickling sensation on his scalp. The paths of Charles Monet and Peter Cardinal had crossed at only one place on earth, and that was inside Kitum Cave. What had they done in the cave? What had they found in there? What had they touched? What had they breathed? What lived in Kitum Cave?
GOING DEEP
EUGENE JOHNSON SAT at a picnic table at Fort Detrick near a duck
pond, leaning forward and gazing at me. It was hot day in the middle of
summer. He was wearing sunglasses. He placed his large elbows on the table, took off his sunglasses, and rubbed his eyes. He was six foot two, maybe two hundred and fifty pounds. His eyes were brown and set deep in his bearded face, and there were dark circles under the lower lids. He looked tired.
"So Peter Tukei got on the phone to tell me that the boy had visited Kitum Cave," Johnson said. "I still get chills when I think about it. A few weeks later, I flew to Nairobi, and I talked with David Silverstein, the kid's doctor. Peter Tukei was with me. Then we went everyplace in Kenya the kid went, even to his house. His parents had a nice house in Kisumu, near Lake Victoria. It was a stucco house with a wall around it, and there was a cook and groundskeepers and a driver. The house was clean and neat, open and whitewashed. We saw that there was a rock hyrax living on the roof. It was a pet, and it lived in the gutters.
There were a couple of storks, and there were rabbits and goats and all kinds of birds. I didn't see any bats around this house."
He paused, thinking. No one else was around. A few ducks swam in the pond. "I was really nervous about talking with the parents," he said.
"See, I am a field person. My wife and I don't have children. I'm not the kind of a guy who can console a mother, plus I work in the U.S. military. I had no idea how to talk to them. I tried to put myself in their place, and I remembered how I felt when my father died. I let them talk about their son, Peter Cardinal and his sister had been inseparable from the moment he arrived in Kenya. The kids had spent the whole time together, doing everything together. So what was the difference in behavior? Why did Peter Cardinal get the virus but not his sister? There was one difference in their behavior. The parents told me a story about the rocks in the cave. They told me their kid was an amateur geologist.
There was this issue: did he cut his hand on any crystals in the cave? We went over that possibility with the parents, Peter had said to them that he wanted to collect some of the crystals in Kitum Cave. So he beat on the walls of the cave with a hammer and collected some rocks with crystals in them. The rocks were broken up by the driver and washed by the cook.
We tested their blood, and they were not positive for Marburg."
It seems possible that the point of contact had been the boy's hands, that the virus had entered Cardinal's bloodstream through a tiny cut. Possibly he had pricked his finger on a crystal that had been contaminated with urine from some animal or the remains of a crushed insect. But even if he had pricked his finger on a crystal, that didn't tell where the virus lived in nature; it didn't identify the virus's natural host.
"We went to look at the cave," he said. "We had to protect ourselves when we went inside. We knew that Marburg is transmitted by the aerosol route."
In 1986 – the year before Peter Cardinal died – Gene Johnson had done an experiment that showed that Marburg and Ebola can indeed travel through the air. He infected monkeys with Marburg and Ebola by letting them breathe it into their lungs, and he discovered that a very small dose of airborne Marburg or Ebola could start an explosive infection in a monkey.
Therefore, Johnson wanted the members of expedition to wear breathing apparatus inside the cave.
"I brought with me these military gas masks with filters. We needed some kind of covering to put over our heads, too, or we'd get bat shit in our hair. We bought pillowcases at a local store. They were white, with big flowers. So the first time we went into the cave, it was a bunch of Kenyans and me wearing these military gas masks and these flowered pillowcases on our heads, and the Kenyans are just cracking up."
They explored the cave and made a map of it. After this scouting trip, Gene Johnson persuaded the Army to sponsor a major expedition to Kitum Cave. Half a year after Peter Cardinal died, in the spring of 1988, Gene showed up in Nairobi with twenty shipping crates full of biohazard gear and scientific equipment. It included several military body bags, for holding human cadavers, and the members of his team had a serious discussion among themselves about how to handle their own remains if one of them died of Marburg. This time, Gene felt that he was closing in on the virus. He knew it would be hard to find even if it lived inside Kitum Cave, but he felt he was getting too close to fail in his quest. The monster lived in a cave, and he was going in there to find it.
The Kenyan government agreed to close Kitum Cave to tourists while the joint Kenya-U.S. expedition searched it for viruses. The head of the expedition was Dr. Peter Tukei of Kenya Medical Research Institute. Gene Johnson conceived the idea and gathered the equipment and found the money to pay for it. There were thirty-five team members, and most of them were Kenyans, including wildlife naturalists, scientists, doctors, and 88 laborers. They brought along a large number of guinea pigs, traveling in boxes, and seventeen monkeys in cages, including baboons, Sykes' monkeys, and African green monkeys. The monkeys and guinea pigs were sentinel animals, like canaries in a coal mine: they would be placed in cages inside and near Kitum Cave in the hope that some of them would break with Marburg virus. There are no instruments that can detect a virus. The best way to find a virus in the wild, at the present time, is to place a sentinel animal at the suspected location of the virus and hope the animal gets sick. Johnson figured that if any of his monkeys or guinea pigs crashed, he would be able to isolate the virus from the sick animals and would perhaps be able to discover how the animals had caught it.
1988 SPRING
THE KITUM CAVE expedition set up headquarters in the Mount Elgon Lodge, a decayed resort dating from the nineteen twenties, when the English had ruled East Africa. The lodge had been built for sporting people and trout fishermen. It sat on a promontory overlooking the red-dirt road that wound up the mountain to Kitum Cave. It had once been surrounded by English gardens, which had partly collapsed into clay and African weeds.
Indoors there were hardwood floors, waxed daily to perfect gleam. The lodge had turrets with round rooms and medieval doors, hand-carved from African olive wood, and the living room boasted an immense fireplace with a carved mantelpiece. The staff spoke very little English, but they were intent on maintaining English hospitality for the rare guest who might happen to show up. The Mount Elgon Lodge was a monument to the incomplete failure of the British Empire, which carried on automatically, like an uncontrollable tic, in the provincial backwaters of Africa long after it had died at the core. In the evenings, as the frost-tinged night came on, the staff built fires of Elgon olive logs in the fireplaces, and the food in the dining room was horrible, in the best English tradition. There was, however, a splendid bar. It was a quaint hideaway in a round chamber, stocked with shining rows of Tusker-beer bottles and French aperitifs and obscure African brandies. The men could sit at the bar and drink Tuskers or lean on the great mantel by the fire and tell stories after a hard day in the cave wearing a space suit. A sign on the wall by the concierge's desk mentioned the delicate matter of money. It announced that since Mount Elgon Lodge's suppliers had cut off all credit to the lodge, the lodge was unfortunately unable to extend any credit to its guests.
They moved the animals up the mountain in stages, to let them get used to the climate. When they got to the valley that leads to the cave, they cleared away some underbrush and put up blue tarpaulins. The cave itself was considered to be a Level 4 hot zone. The tarp closest to the cave covered a gray area, a place where the worlds met. The men took chemical showers under the gray-area tarp, to decon their space suits after a visit to the cave. Another tarp covered a Level 3 staging area, where the men changed in and out of their space suits. Another tarp covered a Level 4 necropsy area. Under that tarp, wearing space suits, they dissected any small animals that they had trapped, looking for signs of Marburg virus.
"We were going where no one had gone before," Johnson said to me. "We brought the Biosafety Level 4 philosophy to the jungle."
They wore orange Racal space suits inside the cave. A Racal suit is a portable, positive-pressure space suit with a battery-powered air supply. It is for use in fieldwork with extreme biohazards that are believed to be airborne. A Racal suit is also known as an orange suit because it is bright orange. It is lighter than a Chemturion, and unlike a Chemturion, it is fully portable, with a self-contained breathing apparatus. The main body of the suit (apart from helmet and the blowers) is disposable, so that you can burn it after using it once or twice.
Wearing their Racal space units, they laid out a trail that wound into Kitum Cave, marking the trail with avalanche poles so that people would not get lost. Along the trail, they placed cages holding the monkeys and guinea pigs. They surrounded the cages with electrified wire, powered by a battery, to discourage leopards from trying to eat the monkeys. They placed some of the monkeys directly underneath bat colonies in the roof of the cave, hoping that something would drop on a monkey that would cause the animal to break with Marburg.
They collected somewhere between thirty thousand and seventy thousand biting insects inside the cave – the cave is full of bugs. "We put stickum paper over cracks in the cave, to catch crawling bugs," Johnson said to me.
"We hung light traps inside the cave to collect flying insects. The light traps were battery powered. You know how to collect ticks? They come out of the ground when they smell carbon dioxide from your breath. They smell it and come up and bite your ass. So we brought these huge tanks of carbon dioxide, and we used it to attract ticks. We trapped all the rodents that went into the cave. We used Havahart traps.
Way at the back of the cave, by a pool of water, we found sand flies.
These are biting flies. We saw leopard tracks all over the place, and Cape buffalo tracks. We didn't take any food samples from large animals, nothing from leopards or buffalo. Nothing from the antelopes."
"Could Marburg live in large African cats?" I asked. "Could it be a leopard virus?"
"Maybe. We just didn't have permits to trap leopards. We did collect genet cats, and it wasn't there."
"Could it live in elephants? Did you ever try to draw blood from a wild elephant?"
We didn't."
The Kenyan naturalists trapped and netted hundreds of birds, rodents, hyaxes, and bats. In the hot necropsy zone, under the tarp, they sacrificed the animals and dissected them while wearing Racal suits, taking samples of blood and tissue, which they froze in jars of liquid nitrogen. Some local people – they were Elgon Masai – had lived inside some of the caves on Mount Elgon and had kept their cattle in the caves. The Kenyan doctors drew blood from their cattle. None of the local people or the cattle tested positive for Marburg antibodies – if they had tested positive, it would have shown that they had been exposed to Marburg.
Despite the fact that nobody showed signs of having been infected, the Elgon Masai could tell stories of how a family member, a child or a young wife, had died bleeding in someone's arms. They had seen family members crash and bleed out, but whether their illnesses were caused by Marburg or some other virus – who could tell? Perhaps the local Masa people knew the Marburg agent in their own way. If so, they had never given it a name.
None of the sentinel monkeys became sick. They remained healthy and bored, having sat in their cages in the cave for weeks. The experiment required that they be sacrificed at the end of the time so that the researchers could take tissue samples and observe their bodies for any signs of infection. At this point, the hard part of primate research began to torment Gene Johnson. He could not bring himself to euthanize the monkeys. He couldn't stand the idea of killing them and couldn't go into the cave to finish the job. He waited outside in the forest while another member of the team put on a space suit and went inside and gave the monkeys massive shots of sedative, which put them to sleep forever.
"I don't like killing animals," he said to me. "That was a major issue for me. After you've fed 'em bananas. That was terrible. It sucked." He put on his orange Racal space suit and opened up the monkeys under necropsy tent, feeling frustrated and sad, especially when all the monkeys turned out to be healthy.
The expedition was a dry hole. All the sentinel animals remained healthy, and the blood and tissue samples from the other animals, insects, birds, Masai people, and their cattle showed no sign of Marburg virus. It must have been a bitter disappointment for Gene Johnson, so disheartening that he was never able to bring himself to publish an account of the expedition and its findings. There seemed to be no point in publishing the fact that he hadn't found anything in Kitum Cave. All that he could say for sure is that Marburg lives in the shadow of Mount Elgon.
What Johnson did not know at the time, but what he sensed almost instinctively after the failure of the Kitum Cave expedition, was that the knowledge and experience he gained inside a cover in Africa, and the space suits and biohazard gear he carried back with him to the Institute, might serve him well at another time and in another place. He kept his African gear hidden away at the Institute, piled in olive-drab military trunks in storage rooms and in tractor trailers parked behind buildings and padlocked, because he did not want anyone else to touch his gear or use it or take it away from him. He wanted to be ready to load it on an airplane at a moment's notice, in case Marburg or Ebola came to the surface again in Africa. And sometimes he thought of a favorite saying, a remark by Louis Pasteur, "Chance favors the prepared mind." Pasteur developed vaccines for anthrax and rabies.
1989 SUMMER
THE ARMY HAD always had a hard time figuring out what to do with Nancy and Jerry Jaax. They were married officers at the same rank in a small corps, the veterinary Corps. What do you do with a married pair of doggy doctors who need to be promoted? What if one of them (the wife) is trained in the use of space suits? Where do you send them? The Army assigned the Jaaxes to the Institute of Chemical Defense, near Aberdeen, Maryland. They sold their Victorian house and moved, bring their birds and animals with them.
Nancy was not sorry to leave the house in Thurmont. They moved into a tract house, which was more to her liking, and there they began to raise fish in tanks, as a hobby, and Nancy went to work in an Army program to study the effects of nerve gas on rat brains. Her job was to open up the rat's head and figure out what the nerve gas has done to the brain. This was safer and more pleasant than working with Ebola, but it was a little dull. Eventually she and Jerry both received promotions to lieutenant colonel and wore silver oak leaves on their shoulders. Jaime and Jason were growing up. Jaime became a superb gymnast, short and wiry like Nancy , and Nancy and Jerry had hopes for her in the nationals, if not the Olympics. Jason grew into a tall, quiet kid. Herky, their parrot, did not change. Parrots live for many years. He went on shouting "Mom! Mom!" and whistling the march from The Bridge on The River Kwai.
Colonel Tony Johnson, Nancy's commanding officer when she had worked at USAMRIID, remembered her competence in a space suit and wanted to get her back. He felt she belonged at the Institute. He was eventually appointed head of pathology at Walter Reed Army Medical Center, and when that happened, his old job came open, the job of chief of pathology at the Institute. He urged the Army to appoint Nancy Jaax to the position, and the Army listened. They agreed that she ought to be doing hot biological work, and she got the job in the summer of 1989. At the same time, the Army appointed Jerry Jaax head of the veterinary division at the Institute. So the Jaax became important and rather powerful figures. Nancy went back to biological work in space suits.
Jerry still didn't like it, but he had learned to live with it.
With these promotions, the Jaax sold their house in Aberdeen and moved back to Thurmont, in August 1989. This time, Nancy told Jerry it was not going to be a Victorian. They bought a contemporary Cape house with dormer windows, with a lot of land around it, meadow and forest, where the dogs could run and the children could play. Their house stood on the lower slope of Catoctin Mountain, overlooking the town, above a sea of apple orchards. From their kitchen window, they could look into the distance over rolling farmland where armies had marched during the Civil War. Central Maryland stretched away to the horizon in folds and hollows, in bands of trees and rumpled field, studded by silos that marked the presence of family farms. High over the beautiful countryside, passenger jets crisscrossed the sky, leaving white contrails behind them.
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